Donation Acceptance Forms
Good Samaritan Medical Dentistry (2)
4/15/2020 3:31:44 PM
4/15/2020 3:31:41 PM
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CITY OF RIVERSIDE <br />Tax ID# 95-600-0769 <br />DONATION ACCEPTANCE FORM <br />Name of Donor: Good Samaritan Medical and Dental Ministry <br />Address: 4343 Market St. #D <br />City: Riverside <br />Description of donation: 200 isolation gowns and 50 Face shields <br />Donor estimate of current value: <br />State: -CA _Zip: 92501 <br />Potential immediate or initial acquisition or installation cost, any on-going maintenance or <br />replacement cost: <br />Intended use: 'City Fire Department <br />Conditions of acceptance or donor designation: <br />None <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.. 9915400885-37422200 <br />APPROVED / DISAPPROVED <br />Date <br />Date <br />Date Submitted to Council <br />Fire / Peter Sellas <br />Department HeaV/Elected Official 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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