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<br />CONTRIBUTOR SUPPORT FORM <br />NO Family Nutrition Program <br />October 1, 2008 - September 30, 2009 <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 446-5100 <br /> <br />Name of Agency I Madison Elementary ~""f >:I,Cn1l~1 <br />e-mail <br /> <br />f <br /> <br />Value 0 Personnel Services (Salary + Fringe Benefits) (Attach documentation) <br />Position Title A x B x C x = D <br /> No. of persons Hourly value Estimated hours Total Yearly <br /> in this Dosition per year to FNP Value <br />Classroom Teachers 10 $61 . 14 80 $4,891.20 <br />Office Staff 2 $22.42 8 $179.36 <br />Principal 1 $65.71 4 $262.84 <br />Para Teachers 3 $22.42 24 $538.08 <br /> Total Value $5,871.48 <br /> <br /> Total Yearly <br /> Value <br />Value of Physical Space (Attach Schedule A AND documentation) <br />. Name of facility: Madison Elementary $568.13 <br />Value of Equipment (Attach Schedule B) <br />Value of Supplies/Materials (Attach Schedule C) <br />Value of Other In-Kind Resources (Attach Schedule D) <br /> <br />OVERALL TOTAL VALUE I <br /> <br />$6,439.61 I <br /> <br />On behalf of Madison Elementary we agree to <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, 2009 . We 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 />Rln ~ <br />Title <br /> <br /> <br />5-1 -rz <br /> <br />Date <br /> <br />Revised 3/08 <br />