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Gift Date:
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Event Name if Applicable:
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Donor Organization/Name:
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Contact Name:
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Phone:
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Email:
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Website (Optional)
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Address:
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Description of item or services donated:
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Pick-up or Delivery notes:
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Donor’s Stated Value:
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Donor Signature:
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Estimated Fair Market Value:
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Name of Individual Completing this Form or Agency Connection
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Date of Entry
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