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

SAMPLE - VOLUNTEER/DONATION FORM FOR IN-KIND

Policy: The Head Start Program matches the amount of Federal funding received with a contribution of 25% from local funding.  In-kind contributions are the source of this match.
Procedure : This form must have both a Volunteer/Contributor’s and a HS/EHS staff/provider’s signature on it before mailing or emailing to DMT.

   CENTER NAME_Central Lake Head Start____________________                MONTH/YEAR October___ /2023__

Date	Detailed Description of Services  
Or Donated Material	Hours or Value 	Rate or Quantity 	Total $ Amount	
10/15/22	Fire Fighter Presentation	1 hour	$20.00	20.00	
10/15/22	Fire Department donated books on fore safety for the lending library	$10.00	5	$50.00	

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

For Office Use Only
Approved by ________________
Date_______________________
Account Number	  Amount
______________	_________
______________	_________
______________	_________
            __________Joe Doe____________________________    
                   Volunteer/Contributor Signature		 	   
______Jane Dane ____________________________
                  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 _________________________________________________________________________________________.
NMCAA is a Private non-profit tax exempt 501-C-3 Agency.  Your In-Kind donation valued at  $__________ may entitle you to a tax deduction, however, your accountant or tax advisor should be consulted.
        __________ Jane Dane ______________	             ___________10/15/22__________
	             HS/EHS Staff/Provider Signature					 Date		
Return to DMT at least monthly, via mail or email                                                        
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