rom 8283 Noncash Charitable Contributions nae

(Rev. October 1986) Expires 9-30-88
> Attach to your Federal income tax return if the total claimed value ‘Attachment

Department of the Treasury

inturnal Revenue Service of all property contributed exceeds $500. Sequence No.

Name(s) as shown on your income tax return Identification number

Include in Section A only items (or groups of similar items) which have a claimed value of $5,000 or less per
item or group and certain publicly traded securities (see instructions).

Information on Donated Property

(a) Name and address of the (b) Description of donated property (attach a

1 donee organization separate sheet if more space is needed)

A

B

c

D

E
Note: Columns (d), (e), and (f) do not have to be completed for items with a value of $500 or less.

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[als Other Information—Complete questions 2 and 3 only if you gave less than the entire interest in property or if
restrictions were attached to the contribution.

2. If less than the entire interest in the property is contributed during the year, complete the following:

(a) Enter letter from Part | which identifies the property ______. (Attach a separate statement if Part II applies to more than one
property.)

(b) Total amount claimed as a deduction for the property listed in Part Iforthistaxyear
for any prior tax year(s)

(c) Name and address of each organization to which any such contribution was made in a prior year (complete only if different from the
donee organization above).

Charitable organization (donee) name

Number and street

City or town, state, and ZIP code’

(d) The place where any tangible property is located or kept.
(e) Name of any person, other than the donee organization, having actual possession of the property.

3 If conditions were attached to the contribution, answer the following questions: Yes | No
(a) Is there a restriction either temporarily or permanently on the donee’s right to use or dispose of the donated property? .
(b) Did you give to anyone (other than the donee organization or another organization participating with the donee ]/
organization in cooperative fundraising) the right to the income from the donated property or to the possession of the y

property, including the right to vote donated securities, to acquire the property by purchase or otherwise, or to 17 Mi,
designate the person having such income, possession, or right to acquire?
(c) Is there a restriction limiting the donated property for a particular use?

For Paperwork Reduction Act Notice, see separate instructions. Form 8283 (Rev. 10-86)


Form 8283 (Rev. 10-86) Page 2
Name(s) as shown on your income tax return. (Do not enter name and identification number if shown on the other side.) Identification number

Appraisal Summary—lInclude in Section B only items (or groups of similar items) which have a claimed value of
more than $5,000 per item or group. (Report contributions of certain publicly traded securities only in Section A.)

Donee Acknowledgment (To be completed by the charitable organization.)

1 This charitable organization acknowledges that it is a qualified organization under section 170(c) and that it received the donated
property as described in Part Il on

Wate)
Furthermore, this organization affirms that in the event it sells, exchanges, or otherwise disposes of the property (or any portion
thereof) within two years after the date of receipt, it will file an information return (Form 8282, Donee Information Return) with the
IRS and furnish the donor a copy of that return. This acknowledgment does not represent concurrence in the claimed fair market

value.
fraritable organization (donee) name imployer identification number
Number and street City or town, state, and ZIP code
‘Authorized signature Title Date

GEMM] Information on Donated Property (To be completed by the taxpayer and/or appraiser.)

2 Check type of property:
0 art* OO Real Estate O Gems/Jewelry
C1 Stamp Collections C1 Coin Collections 0 Books 0 Other

*Art includes paintings, sculpture, watercolors, prints, drawings, ceramics, antique furniture, decorative arts, textiles, carpets, silver, rare manuscripts,
historical memorabilia, and other similar objects.

3 (a) Description of donated property (attach a (b) Date acquired (¢) How acquired (d) Donor’s cost or (e) Appraised fair market
separate sheet if more space is needed) by donor (mo., yr.) by donor adjusted basis value

A

B

c

D

4 Iftangible property was donated, write a brief summary of the overall physical condition of the property at the time of the gift

Taxpayer (Donor) Statement (To be completed for items listed in Section B, Part Il, with appraised value of $500

orless peritem.) _
| declare that item(s) (enter letter(s) identifying property) listed in Part ll above has (have) to the best of my knowledge and belief an
appraised value of not more than $500 (per item).
Signature of taxpayer (donor) > Date >

ig'4 Certification of Appraiser (To be completed by the appraiser of the above donated property.)

| dectare that | am not the donor, the donee, a party to the transaction in which the donor acquired the property, employed by or related to any of the
foregoing persons, or a person whose relationship to any of the foregoing persons would cause a reasonable person to question my independence as an
appraiser.

Also, | declare that | hold myself out to the public as an appraiser and that because of my qualifications as described in the appraisal, | am qualified to
make appraisals of the type of property being valued. | certify the appraisal fees were not based upon a percentage of the appraised property value.
Furthermore, | understand that a false or fraudulent overstatement of the property value as described in the qualified appraisal or this appraisal summary
may subject me to the civil penalty under section 6701(a) (aiding and abetting the understatement of tax liability). | affirm that | have not been barred from
presenting evidence or testimony by the Director of Practice.

Please

Sign

Here | Signature Title> Date of appraisal >

Business address identification number

City or town, state, and ZIP code