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<br />\ <br /> <br />CONTRIBUTOR SUPPORT FORM <br />NO Family Nutrition Program <br />October 1, 200f - September 30, 200. <br />I <br /> <br />Your intention to pledge in-kind value to FNP is considered a local match to the Federal dollars that support the <br />Family Nutrition Program. Though your pledge of time or use of equipment does not represent an actual cash outlay by <br />your organization to the FNP program, it is necessary for us to place a monetary value on that pledge in order to receive <br />an equivalent amount of Federal funding. Please assign dollar values consistent with your agency financial records; <br />when in doubt, please assign a conservative estimate. <br />Thank you very much for your pledge to our program. It is essential for our continuing operation to have this <br />demonstration of local community support. <br /> <br />County Cass <br />Contact Person Chris Triggs <br />Phone 701-446-5100 <br /> <br />Name of Agency I FPS - Madison <br />E-mail <br /> <br />VI <br /> <br />fP <br /> <br />IS <br /> <br />(S <br /> <br />B f) <br /> <br />x <br /> <br />b <br /> <br />a ue 0 erso"ne ervlces alarv + Fringe ene Its a = C <br /> Position Title No. of persons Hourly value Estimated hours Total Yearly <br /> in this position per year to FNP Value <br /> Teachers 11 $58.70 150 $8805.00 <br /> Office Staff 2 $21.65 10 $217.00 <br /> Principal 1 $63.16 5 $316.00 <br /> Total Value $9337.00 <br /> <br /> Total Yearly <br /> Value <br />Value of Physical Space (Attach Schedule A AND documentation) <br />. Name of facility: Madison Elementary <br /> $7786.00 <br />Value of Equipment (Attach Schedule B) <br />Value of Supplies/Materials (Attach Schedule C) <br />Value of Other Resources (Attach Schedule D) <br /> <br />OVERALL TOTAL VALUE I <br /> <br />$17,123 <br /> <br />On behalf of Madison Elementarv <br /> <br />we agree to <br /> <br />(Name of Agency) <br />contribute the above in-kind resources to support the Family Nutrition Program during the project year <br />through September 30,-2QQI" ',Ve certify that we have public, non-federal funds/services available for <br />matching the Family Nutrition Program and that these funds are not used to match other Federal <br />programs. <br /> <br /> <br />~ Prl' <br /> <br />Title <br /> <br /> <br />5/.22- (J <br />Date <br /> <br />Revised 1/07 <br />