NORTHWEST MICHIGAN COMMUNITY ACTION AGENCY, INC.
3963 THREE MILE ROAD
TRAVERSE CITY, MICHIGAN 49686

SAMPLE VOLUNTEER/DONATION FORM FOR INKIND

CENTER NAME_ Central Lake Head Start__        MONTH ___October____          YEAR    ___2012___

DATE	Description of Services or 
Donated Material	Hours or Value 	Rate or
Quantity 	Total $ Amount	
10/15/19	Fire Fighter Presentation	       1 Hour	   $20.00	    $20.00	
10/15/19	Fire Department donated books on fire safety for the lending library	      $10.00	        5 	    $50.00	

					
					
								        GRAND TOTAL __$70.00__ certify that the above contribution has been made.

                                ______Joe Doe______      	    ________Jane Dane_________________       
For Office Use Only
Approved by ________________
Date_______________________
Account Number	  Amount
______________	_________
______________	_________
______________	_________
            Volunteer/Contributor Signature		 	              HS/EHS Staff/Provider Signature

Receipt Requested?  (Please Check)
__X___ Yes		_____ No

If yes, complete name and address:
Contributor’s Name: ____ Joe Doe____________
Address: _210 State St_____________________
City, State and Zip: _Central Lake, MI 49622__

*Use this form for items that are donated and will remain at the center. This form is also used for classroom visitors (firefighters, dentists, etc.) and volunteer services for the center. Include the presenter’s/volunteer’s rate of pay on this form along with signatures of volunteer and staff. Send top portion of the form to DMT and if a receipt is requested, complete the bottom portion of the form and give it to the volunteer donating their time and/or materials.			
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _  _ _ _ _  _ _  _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 
 RECEIPT OF DONATIONS FROM:

The Northwest Michigan Community Action Agency, Inc. would like to thank you for your contribution of     Presentation and book donation__________________________________.
NMCAA is a Private non-profit tax exempt 501-C-3 Agency.  Your Inkind donation valued at 
$__$70.00______ may entitle you to a tax deduction, however, your accountant or tax advisor
 should be consulted.
_____________ Jane Dane_____________	_____________10/15/19_______________
    Signature				        Date       

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