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CITY OF RIVERSIDE <br /> Tax ID#95-600-0769 FEB 2 7 201,3 <br /> DONATION ACCEPTANCE FORM City of Riverside <br /> \ City C�� �k s Office <br /> Name of Donor: reg^'�\ L1Ub o� Q� (S.1 ae-- <br /> ,ves ►(k' CA q-25°G <br /> Address: 'G\SS 4{atk�*'"0`� ? City: R State: Zip: <br /> Description of donation: CK \(‘31C, 5,000 <br /> Donor estimate of current value: 0/fl <br /> Potential immediate or initial acquisition or installation cost, any on-going maintenance or <br /> replacement cost: N • <br /> Intended use: <br /> 12iVc.rciU't, 001 - bC ` - 'Jr <br /> Conditions of acceptance or donor designation: /t)/A <br /> Remarks: No Goods or Services were provided by the City in exchange for the donation <br /> City Department and City Representative receiving donation: SG-T. ►" i 16`/ <br /> Deposit Account Code: O v a 2,0 - 2251y O <br /> APPROVED/ DISAPPROVED <br /> 2--it- ktA.6 <br /> Date Department Head/Elected Official Signature <br /> Date Chief Financial Officer Signature (if needed) <br /> Date Submitted to Council Date Approved by Council (if needed) <br /> Note:The City of Riverside cannot guarantee future funding for repair, maintenance, use or replacement <br /> of donated items. <br /> Original to City Clerk <br /> cc:City Council, Finance Department, Receiving Department <br />