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ND Family Nutrition Program I Form.A I <br /> <br />CONTRIBUTOR SUPPORT FORM <br /> <br />October 1, 2004 - September 30, 2005 <br /> <br /> Your gift of a donation or service is considered a local match to the Federal dollars that support the Family <br />Nutrition Program. Auditing guidelines require that the donor information requested below be kept on file by our <br />project administrators. Though your gift 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 gift, in order to <br />receive an equivalent amount of Federal funding. Please assign dollar values consistent with your <br />company/agency financial records; when in doubt, please assign a conservative estimate. <br /> Thank you very much for your gift to our program. It is essential for our continuing operation to have this <br />demonstration of local community support. <br /> <br /> County/Site <br />Name of Agency <br /> Contact Person <br /> Address <br /> Phone <br /> E-mail <br /> <br /> Cass County <br />Juvenile Detention <br /> Tim Olson <br />1010 2''a Ave S, i-argo ND 58103 <br />241-5845 <br /> <br />Value of Personnel Services (Salary + Fringe Benefits) <br /> <br /> Position <br />(Name and Title) <br /> <br /> a X b = c <br /> <br />Hourly value Estimated hours Total Yearly <br /> per year to FNP Value <br /> <br />Juvenile Officer (B22) <br /> <br />Juvenile Officer (B22) <br /> <br />Tim Olson, Supervisor <br /> <br />$21.75 180 $3915.00 <br />$21.75 180 $3915.00 <br />$28.32 10 $283.20 <br />Total Value $8113.20 <br /> <br />Value of Physical Space <br />include documentation <br /> <br />Name of facility <br /> <br />(Attach completed and signed "Facilities Space Valuation Worksheet" Form B) and <br /> <br /> Total Yearly <br /> Value <br /> <br />Total Value <br /> <br /> <br />