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CITY OF RIVERSIDE <br />Tax ID# 95-600-0769 <br />DONATION ACCEPTANCE FORM <br />Name of Donor: Blue Shield of California <br />RECEIVED <br />MAY 08 2019 <br />City of Riverside <br />City Clerk's Office <br />Address50 Beale Street City: San Francisco State: CA Zip: 94105 <br />Description of donation: Wellness Fair 2019 <br />Donor estimate of current value: $300.00 <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 />05/08/2019 <br />Date ment Head/ lected 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 repa <br />of donated items. <br />Original to City Clerk <br />cc: City Council, Finance Department, Receiving Department <br />aintenance, use or replacement <br />
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