Donation Acceptance Forms
Good Samaritan Medical Dentistry
4/6/2020 2:22:19 PM
4/6/2020 2:22:17 PM
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CITY OF RIVERSIDE <br />Tax ID# 95-600-0769 <br />DONATION ACCEPTANCE FORM <br />Name of Donor:�ec(�ca:�204Pdpeh�( <br />Address: �3�04�Ldlr 4z _city: Rj'Vei-<-10d,e State: Zip: _7,;)-�a d f <br />Description of donation: A)(2 ajdSk-s, % adwr 3D ck'elds. 30 baVtw <br />S�y7 r � i 7 �f''=S <br />Donor estimate of current value: 4 qV i� <br />Potential immediate or initial acquisition or installation cost, any on-going maintenance or <br />replacement cost: <br />Intended use: /o r - <br />Conditions of acceptance or donor designation: - /�2 /k4 - <br />Remarks: No Goods or Services were provided by the City in exchange for the donation <br />City Department and City Representative receiving donation: <br />Deposit Account Code: <br />APPROVED/DISAPPROVED <br />Dat" Depa <br />Date <br />Date Submitted to Council <br />.on <br />vc-A-1- 56, llec- <br />/ElecteVOfficial Signature! <br />Chief Financial Officer 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 />
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