RECEIPT FOR PROPERTY

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					                                          RECORD OF AND RECEIPT FOR CONTRIBUTIONS



                               FACILITY                                                              DATE


Fill in applicable blanks below.
                                                                                                    COUNTY

Name of Person(s) or Organization


Address of above: Street/Route              City                         State       Zip Code             Telephone


Contact Person/Address if Different from above


Note description of contribution or donations (Use back, if necessary)




Received By:                                                      Title:



Please be advised that items may be sold with proceeds going to the facility or project for which the contribution was intended.

This form may serve as a receipt for tax purposes if the individual or firm desires. Estimates of the value of contributed items are
the responsibility of the contributor.
SCDMH FORM
NOV. 90 (REV. DEC. 05)   V-7
Note description of contribution or donations (back)




Received By:                                                      Title:



Please be advised that items may be sold with proceeds going to the facility or project for which the contribution was intended.

This form may serve as a receipt for tax purposes if the individual or firm desires. Estimates of the value of contributed items are
the responsibility of the contributor.
SCDMH FORM
NOV. 90 (REV. DEC. 05)   V-7