Gift Reimbursement/Receipt Form

2. Date

3. Name of Reporting Individual:

4. Name of Donor:

6. Description of Gift Received:

7. Value of Gift:

9. Amount of funds paid as reimbursement by reporting individual or in-kind consideration furnished by reporting individual:

   Indicate funds paid as reimbursement for gift or return of bottle of water for water bottle received

11. I,

    Donor

12. do hereby acknowledge that I have received payment in the amount of

    Amount

14. or of in-kind consideration of

    Consideration

15. from

    Reporting Individual

16. for the receipt of

    Gift

18. with a value of

    Value

19. on

    Date

20. By:

    Signature

21. Print Name

Leave This Blank:


22. Print Only

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