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CITY OF RIVERSIDE RECEIVED <br />Tax ID# 95-600-0769 NOV 15 2019 <br />DONATION ACCEPTANCE FORM <br />City of Riverside <br />Name of Donor: HUB International <br />City Clerk's Office <br />AddressPO Box 2158 <br />City: Riverside State: CA Zip: 92516 <br />Description of donation: Wellness Donation <br />Donor estimate of current value: $6,502.89 <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 for Wellness Incentives <br />Conditions of acceptance or donor designation: Wellness Program <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: 2100001-453221 <br />APPROVED / DISAPPROVED <br />11/07/2019 <br />Date <br />Date <br />Date Submitted to Council <br />e"Head/ElecOfficial Signature <br />Chief Financia is Signature (if needed) <br />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 />