PSCQZAB Form 1

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					                                                                                                                  PSC/QZAB Form 1.3-R

                                     STATE OF MARYLAND
                               Public School Construction Program                                           PSC/QZAB #
                                      200 W. Baltimore Street
                                       Baltimore, MD 21201                                                  Date Submitted

                    QZAB PRIVATE ENTITY CONTRIBUTION TRACKING FORM
LEA:                                                                         Name of School:
                                                                                        Address:



Total Amount of QZAB utilized $

Total Amount of contribution required (10%) $                                          (present value)

Date Project approved:

Date project started:

Date project completed:


                                                                        Face Value      Monthly QZAB        Present Value
  Date of                                                 Type of            of         Present Value            of       Total Present Information
Contribution Contributor(s)                             Contribution(1) Contribution     Multiplier(2)      Contribution Value to Date entered by:




       Total
(1) Use type of contribution from PSC/QZAB Form 1.1R
(2) See reverse for the “Monthly QZAB Present Value Multiplier”

          I hereby certify that the information above is an accurate and true portrayal of the contributions that have been donated by the private
          sector and reflects an accurate present value. These items have been donated to meet the requirements of the Qualified Zone
          Academy Bond Program project at the above-cited school. The contributions donated total $                    in present value as of
          November 30, 2004 and represents at least 10% of the QZAB proceeds used for the project at this school.



Superintendent of Schools                                                                                Date

				
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