MISC-400
Cooperative Extension Service Gift Disclosure Form	01/13/2021
For Cash and Non-Cash Gifts
Already Deposited	Check Attached	Non-cash Gift	Stock	Land
Section A. Donor Information
Name of Donor(s):
Contact Name, if applicable:	Is this a joint gift?	Yes	No
Address:	Anonymous gift:	Yes	No
Telephone:
*Email:
Tax Receipt Required:	Yes	No
* Optional fields
If an entity other than the donor(s) listed above should receive gift credit or should receive a letter of acknowledgement in addition to the entity(ies) above, please provide name(s) and address(es) on a separate sheet of paper.
Section B. Account Information for Gift Deposits
Cost Center:	Driver Worktag:	Amount:$
Cost Center:	Driver Worktag:	Amount:$
Section C. Gift Information
This gift is in memory or in honor of:	Description of Noncash Gift(s) (include make, mode, serial#):
Name:
Address:
This gift qualifies for a matching gift.	Goods and/or services were returned to donor(s) in exchange for this gift (quid-pro-quo.) Example: For a fundraising event, such as a golf tournament, the fair market value of goods and/or services provided (e.g. green/cart fees, meals, etc.) to participants must be reported in acknowledgment letters.
Yes (Enclose Form)	No
Thank You Note Sent to Donor:	Yes	No
Yes (Value: $ ) No
INCLUDE ALL DOCUMENTATION RECEIVED FROM DONOR AND COPY OF CHECK (IF APPLICABLE)
Employee receiving the gift	Date:
Fund Manager Signature (Required):	Date:
Director of Development:	Date:
Forward to Development Office: DevelopmentOffice@uada.edu.