Exhibit A
DONATION ACCEPTANCE FORM
1. Donor Information
Name: ________________________________________________
Organization (if applicable): _______________________
Address: _____________________________________________
City/State/Zip: _____________________________________
Phone/Email: _______________________________________
2. Donation Description
Type of Donation (check one):
☐ Monetary Donation
☐ In-Kind Donation
Detailed Description:
_________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Estimated Fair Market Value (for in-kind donations): $__________________ Amount (for monetary donations): $__________________
3. Purpose of Donation
☐ Undesignated
☐ Designated (describe purpose):
_________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________
4. Conditions or Restrictions (if any)
_________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Exhibit A
5. Receiving Department
Department Name: _________________________________
Department Contact: _______________________________
6. Compliance Review
The undersigned certify that:
a. The donation serves a legitimate public purpose;
b. Acceptance complies with applicable laws and City policy; c. The donation does not create a conflict of interest or undue influence; and d. Any costs or liabilities have been evaluated and determined to be acceptable to the City.
7. Approval Routing
Director of Finance (or Designee)
Name: __________________________________________
Signature: ______________________________________
Date: ___________________________________________
Approval Authority (check one):
☐ City Manager (or Designee) – for donations ≤ $10,000
☐ City Council Approval Required – donations > $10,000
City Manager (or Designee)
Name: __________________________________________
Signature: ______________________________________
Date: ___________________________________________
Mayor (if City Council approval is required)
Name: __________________________________________
Signature: ______________________________________
Date: ___________________________________________
City Council Approval Date (if applicable): ______________________