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CITY -OF -RIVERSIDE <br />Tax ID# 95-600-0769 <br />DONATION ACCEPTANCE FORM <br />Name of Donor: Walmart <br />Address: 6250 Valley Springs Pkwy City: Riverside State: CA Zip: 92507 <br />Description of donation: Check in the amount of $1,000 <br />Donor estimate of current value: $1,000 <br />Potential immediate or initial acquisition or installation cost, any on-going maintenance or <br />replacement cost: None <br />Intended use: To purchase smoke alarms for residents in the city of Riverside. <br />Conditions of acceptance or donor designation: <br />Remarks: No Goods or Services were provided by the City in exchange for the donation <br />City Department and City Representative receiving donation: Fire Department <br />Deposit Account Code: 350000-374222 <br />APPROVED/DISAPPROVED <br />Date Department 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 repair, maintenance, use or replacement <br />of donated items. <br />Original to City Clerk <br />