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Form 0203 (nevi 122000)
<br />Naivete) Dhow, on your Income Inc rolurn
<br />T Pogo 2
<br />1 Identifying number
<br />Suction S. Donated Property Over $5,000 (Except Certain Publicly Trndod Socuritios) —list In this section only items (or groups of sin filar
<br />Items) for which you ciaknect a deduction of more than $5,000 per item or group (except con kilo 'lions of 0011311) publicly 11 at led
<br />securities reported In Section A). An apps else' Is generally 1 aq tired for properly listed In Section 13 (.son Insll tic lions).
<br />CCM Information on Donated Property—To be completed by the taxpayer and /or the appraiser.
<br />4 Check the box That describes the typo of pr opor ly donated: -
<br />❑ Art' (contribution of $20,000 or more) [1 ()Implied Conservation Contribution [_j rqulpmenl
<br />❑ Art' (contribution of loss than $20.000) [.l (Mier Heal Estate 1.1 Securities ❑ Collectibles" [1 Intellectual Property [_) 011cer
<br />'Art Includes painlings) sculpture!), watercolors, pdnl9, drawings, cMneda9, nnlicNnq dncorelive girls. bellies, ctapnIs, silver, rare near scripts, historlcnl nrnmornbisa. and
<br />ocher °linear obl0019.
<br />"Collectibles Include coins, stamps, books, gems, Inwetry, sports mmnorn1)111o. delis, elc., but not err es dationtl ,hove.
<br />Note. In certain cases, you must 0110011 0 qualified emu -Mont of tho property. Soo Instructions.
<br />5 In) Description of donated properly 01 you ,,girt (b) 11 InngIblo properly was donated, give 0 brief summery of gm overnll (y) Appraised lair
<br />mom apace, attach 0 soperale statement) physlcei condition of the re owe ly 0l I1hho -Ilea 01 the gill n,mkni value
<br />A Jce;% �-- Cl. £. ,A-Lci d �ll_� ��a,
<br />0
<br />mot',( r. >._ (_.- ....'.7 i
<br />D
<br />(6) Onto acquired
<br />by donor (mo., yr.)
<br />(e) [low acgnlrod (q IMnor's cost or
<br />by donor nd1os1nd bnslo
<br />A (iiLK/1L 0
<br />Part 11
<br />ISO roc bargain soteq Nor See imlbucllons
<br />emoted reeelvnlf (I,) Amount ciolmod 119 n eti Average finding 1 rice
<br />deduction of securities
<br />Taxpayer (Donor) Statement—List each item included in P i i I above that the ap rraisal identifies as having
<br />a value of $500 or less. See instructions.
<br />I declare that the following item(s) Included In Part I above has to the bast of my knowl aloe and bollof an appralrod value of not more than ti-r0))
<br />(per Item). Ent or Identifying lot tor from Part I and describe the specific item. See insiruc ions.
<br />/1/4% SIlnaluro of taxpayer (donor) i. Oaio
<br />Part 111 Declaration of Appraiser
<br />I declare that I am not the donor, the donne, a party to rho transaction In which tiro donor acquired lho property, employed by, or totaled 10 any of the forogoing persons. or
<br />manlod to any porson who Is related to any of the foregoing persons. And, If regularly used by the donor, Junco, or per ly to Pm transaction, I immlonnnd the mniudly of my
<br />appraisals during my tax year for other persons.
<br />Also, I declare that I hold myself out to the public as an appraiser or perform appraisals on a regular basis; and That bocauso of my qualifications as described In Inc
<br />appraisal, I am qualified to moko npprolsals of tho typo of properly being valued. I certify that the appraisal foes wore not based on a percentage al the appraised property
<br />value. rurthormoro, I understand that a (also or fraudulent overstatement of the properly value as descl ibod In tiro qualified appraise) or tills form 0203 !nay subloct ern to
<br />Rho ponelty under suction 6701(a) (aiding and eliciting rho uriderslalonimd of lax liability). In addition, 1 undostand Mat a substantial or gross valuation mIsslalomen)
<br />resulting from the /reprersal of the value of We moody that I know, or reasonably sbmrd know, would be used In connection with a rolurn or claim for refund, may sorrierI
<br />me to tiro penalty under section 6695A. I affirm that I have not been barred from pronorably evidonco or ((neurally by tiro Office of Plofossional nosponslbilily,
<br />Sign _
<br />Here signature te )-PeQ / -_ — ...._. 0._e
<br />'— j._ /
<br />Business address (including room o Y uo nu.l jidc s •)-.. o
<br />-r. N_
<br />City or town, slate, and ZIP code
<br />part' IV+
<br />Donee Acknowledgment —To be completedy the charitable organization. nib )
<br />This charitable organization acknowledges that It le a qualified organlzallon under section i 70(o) and that it received the donated properly as described
<br />In Section 0, Part 1, above on the following date P
<br />Furthermore, this organization affirms that In the event 11 sells, exchanges, or otherwise disposes of the proporty described in Section 0, Pad I (or any
<br />portion thereof) within 3 years after rho data of receipt,11 wilt Isle Form 0202, Dmioo Information Return, with Iho Ind and give the donor a copy of that
<br />(ore, This acknowledgment doos not represent agreement with the claimed lair market vniuo.
<br />Does the organization Intend to use the property for an unrolatod use? l• U Yes ❑ No
<br />Name oI charlloble organizalron (donee) Employer Identification number
<br />6
<br />(� (,,t a 4- L.c- f-fhr' (1' A✓% P4
<br />Address ( mber, street, and room or sulfa no.) City or town, stela, and ZIP code
<br />Autlodzod signature
<br />Theo I O:ao
<br />® 0,rnr0A r., me yang Popor Fm n1 8283 (env. 12 -2006)
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