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

VOLUNTEER/DONATION FORM FOR INKIND

Policy: 1303.4: A grantee must contribute 25 percent as non-federal match each budget period.  

Procedure:  Complete in ink.  This form must be mailed to DMT.
CENTER NAME_______________________MONTH _________________ YEAR _________

Date	Detailed Description of Services  
Or Donated Material	Hours or Value 	Rate or Quantity 	Total $ Amount	

					
					
								                    GRAND TOTAL $__________
I certify that the above contribution has been made.

            _______________________________________________    
                   Volunteer/Contributor Signature		 	   
______________________________________________
                  HS/EHS Staff/Provider Signature
For Office Use Only
Approved by ________________
Date_______________________
Account Number	  Amount
______________	_________
______________	_________
______________	_________

Receipt Requested?  (Please Check)
_____ Yes		_____ No

If yes, complete name and address:
Contributor’s Name: __________________________
Address: ____________________________________
City, State and Zip: ___________________________

*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 _________________________________________________________________________________________.
NMCAA is a Private non-profit tax exempt 501-C-3 Agency.  Your Inkind donation valued at  $__________ may entitle you to a tax deduction, however, your accountant or tax advisor should be consulted.
        
        _____________________________________	             ___________________________________
	                          Signature						       Date		
Return to DMT at least monthly
Reference: HS Standard 1303.4

1/19	                                                                                                                                                                                         P:\Head Start Files\ADMIN\Procedures manual \Inkind\Volunteer Form