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
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22. Print Only

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