1062.02A
Donation Acknowledgement and Receipt
Including a Statement of Donor’s Intent
To be used to acknowledge and provide a receipt for donations other than those involving Employee
Recognition Funds or the Border Security and Immigration Legal Defense fund.
TOP SECTION FOR USE BY DONOR
Name of Donor:
(Individual or Organization)
Street Address:
City: State: Zip:
Amount Donation in Cash $
Description of Non-Cash Donation
Description of goods or services provided to Donor in
Exchange for the Contribution*
Estimated Value of Goods or Services provided to Donor
in Exchange for the Contribution
$
*Includes tangible items such as tickets to events, gift cards, etc., as well as intangible items such as services like car washing, etc.
It is the intent of the Donor that this donation be used for the purpose set forth immediately below. I authorize the State of
Arizona and/or the Receiving Agency to determine the best use of this Donation consistent with this intent. The Donor places no
other restrictions, terms or conditions on this Donation.
Donor acknowledges that donations other than cash may be sold or otherwise disposed of and that their proceeds then used in a
manner consistent, to the extent practicable and conforming to law,
with the Donor’s intent. Donations are accepted with the
understanding that they are not refundable except at the option of the State of Arizona, that they carry no time limit or expiration
date, that they have been freely given, and that their acceptance creates no corresponding obligation on the part of the State of
Arizona, its agencies, divisions or departments or its agents or employees, other than to be used, to the extent practicable and
conforming to law, in a manner consistent with Donor’s intent.
Signature of Donor or Donor’s Agent: Date:
Title (Donor/Agent/Executor/Officer):
Please ask for and retain a copy of this acknowledgment, signed below, for your records. Please consult your tax
advisor as to the potential deductibility of this donation for tax purposes.
Thank You for Your Support!
SECTION BELOW FOR USE BY THE STATE OF ARIZONA
Signature of Receiving Employee: Date:
Printed name of Receiving Employee: EIN:
Title, Division, and Agency of Receiving Employee:
