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CITY OF RIVERSIDE <br />Tax ID# 95-600-0769 <br />DONATION ACCEPTANCE FORM <br />Name of Donor: Penn Tran OD Inc. Eye -C -You Optometry <br />RECEIVE <br />MAR 2.9 2019 <br />tyof Cler'k's� <br />rside <br />City Office <br />Address: 1299 University Ave, Suite 103 City: Riverside State: CA Zip: 92507 <br />Description of donation: Wellness Fair 2019 <br />Donor estimate of current value: $50.00 <br />Potential immediate or initial acquisition or installation cost, any on-going maintenance or <br />replacement cost: N/A <br />Intended use: Funds will be used to host the Wellness Fair <br />Conditions of acceptance or donor designation: Host Wellness Fair <br />Remarks: No Goods or Services were provided by the City in exchange for the donation <br />City Department and City Representative receiving donation: Human Resources - Stephanie Holloman <br />Deposit Account Code: 2100000-453221 <br />APPROVED / DISAPPROVED <br />03/27/2019 <br />Date <br />t Head/Elect <br />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 />