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CITY OF RIVERSIDE <br />Tax ID# 95-600-0769 <br />DONATION ACCEPTANCE FORM <br />Name of Donor TkQ 1 Q 430r pa A— Ca (' <br />Address: V1S "Htnh+ 12-.A • City: 21 -Q-+'sem-Q- State:'-- Zip:4;1c9-S1)1/4-1 <br />Description of donation: <br />Donor estimate of current value: 4-l -VCD • CAD' <br />Potential immediate or initial acquisition or installation cost, any on-going maintenance or <br />replacement cost: <br />Intended use: ada-t--ft 1.�c 1 c5v Lec�-p-i-zc�� <br />V -L PY t7_ <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: C, C' S OP -e-; C� <br />Deposit Account Code: 1a.oc000 `-tSt)3a'1 a <br />APPROVED / DISAPPROVED <br />-3(14117)0/ <br />Date Depart en Head/Elected 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 />cc: City Council, Finance Department, Receiving Department <br />