Circle of Care St. Louis — In-Kind Donation Form

Circle of Care St. Louis — In-Kind Donation Form

Share your donation details and a good-faith estimated fair market value for recordkeeping and acknowledgment.
Donor Information
Donor Type

Other
Donor or Organization Name
Primary Contact Name

First NameLast Name
Email
example@example.com
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Mailing Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Permission to Publicly Recognize This Donation
Recognition Name
Donation Information
Donation Status
Donation Date / Proposed Donation Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Donation Category

Other
Detailed Description of Donated Items
Are All Items New and Unopened?
Condition of Mobility/Durable Equipment
Approximate Total Quantity / Number of Items
Upload Photos of Items

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How Will the Donation Be Provided?

Other
Estimated Value of In-Kind Donation
For recordkeeping purposes, please provide your good-faith estimate of the fair market value of the donated property. The donor is responsible for determining the value of an in-kind contribution. Circle of Care St. Louis does not appraise or assign a value to donated property.
Estimated total fair market value of donation (USD)
How was the value determined?

Other
Upload receipt, invoice, or other valuation documentation

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Does any single donated item have an estimated value of $500 or more?
Notes about valuation
Donation Acknowledgment
Agreement Statements
Electronic Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Please review each statement carefully before signing.
Your signature confirms your acknowledgment and agreement to the statements above.
This acknowledgment is required to complete your in-kind donation submission.
Should be Empty:

Circle of Care St. Louis — In-Kind Donation Form

Donor Information

Donation Information

Estimated Value of In-Kind Donation

Donation Acknowledgment