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CITY OF RIVERSIDE <br />Tax ID# 95-600-0769 <br />DONATION ACCEPTANCE FORM <br />Name of Donor: Inland Empire Health Plan <br />Address: PO Box 1800 City: Rancho Cucamonga State: CA Zi81 <br />City <br />Description of donation: $2000 Sponsorship check <br />2019 <br />Donor estimate of current value: $2000.00 <br />Potential immediate or initial acquisition or installation cost, any on-going maintenance or <br />replacement cost: NA <br />Intended use: Sponsorship of the Deaf Awareness Week Activities <br />Conditions of acceptance or donor designation: Offset expenses of Deaf Awareness Week <br />Remarks: No Goods or Services were provided by the Citv in exchange for the donation <br />City Department and City Representative receiving donation: Office of the Mavor-Kathv Young <br />Deposit Account Code: 0120000-374222 <br />Exp. Account Code: 0120000-450008 <br />APPROVED / DISAPPROVED <br />Date <br />Depat#fnent 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 />