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Form 0203 (Ilov. 122000)
<br />7 Pogo 2
<br />Nania(s) shown on your income lox return Identifying number
<br />Section 8. Donated Proporty Over $5,000 (Except Certain Publicly Traded Socurities) —I_Ist In this section only items (or groups of similar
<br />Items) for which you claimed a deduction of more than. $5,000 per Rein or group (except contributions oI coo tale publicly traded
<br />securities reported In Section A). An appraise) is generally required for properly listed In Section (3 (see Irishuctlons).
<br />Information on Donated Property zro be completed by the taxpayer and /or the appraiser.
<br />4 Check the box that describes the typo of proper ly donated:
<br />[.1 Art' (contribUtlon of $20,000 or Inoro) ❑ qualified Consorvotion Contribution [-j Equip110111
<br />❑ Arl' (conldbulion of loss than $20,000) [.J Other (teal Estate U Securities
<br />❑ Collectibles" (_I intellectual Property [_J Other
<br />'Art Includes paintings. sculptures, watercolors, prints, Nnwlnps, ceramics, nnllquo %, decorative arts. loxIllos, carpels, silver, rare 119 nuscr ipl v, his to ic0l nemn0l
<br />other similar obkxis.
<br />"Collectibles Include coins, sI911105. books, pones, Inwolry. sports menlornbllin, dolls, olc., but not ore as defiled above.
<br />Note. in certain cases, you must attach a qualified appreient of lie properly. Soo instructions.
<br />Part
<br />5 (o) Descdpllon of donated props ty (it y011 need (b) II 10nglbia ploporly was donator]. give 0 Mot summary of Ihn ovamll
<br />more apace, 011,101, n sopnrolo statement) physical condition of the ploporly el Iho lima of Iho pill
<br />A
<br />8
<br />C
<br />D
<br />.4F17\r —_fie. 0AK:
<br />(d) Dale ncgsrod
<br />by dolor (mo., yr.)
<br />(et Flow acquired
<br />by donor
<br />ef. �11tS
<br />(q nurse's cost or (f), for bargain sales, enter _ Svc
<br />adjusted basis mount received X71 Arimunl clalnmd ns n
<br />deduction
<br />(j)
<br />(c) Appraised Inir
<br />market value
<br />:md
<br />l_t
<br />300 00
<br />11110000119
<br />�. Avmago ha NU lairs
<br />of scow illos
<br />Taxpayer (Donor) Statement - -List each item it in P I above that the appraisal identifies as having
<br />a value of $500 or less. See instructions.
<br />1 decioro that the following Item(s) included In Part 1 above has to the host of my krlowl Klee and belief an appralsod value of not more than $1100
<br />(per Item). Enter identifying letter from Pail 1 and doscdbo 1110 specific limn. See instruc ions.
<br />Slgnaluro of taxpayer (donor) re Date P
<br />Declaration of Appraiser
<br />Part :111
<br />I declare that I em not the donor, Iho donee, a party to Iho transaction 111 which 1110 donor acquhaf Iho propody, omployod by, or related to any of the fompoing persons. or
<br />teamed to any person who Is related to any of rho loregolnq 0019011s. And, it rot/Wally used by We donor, donee, or patty to the lransaction,1 pot formed Iho nlalorily of my
<br />opptalsals during my tax year for other persons.
<br />Also, I declare that I hold myself out to the public as on appraiser or pmlonn appraisals on a regular basis; and that because of my qualifications as described In the
<br />appraisal, l em qualified to make appraisals of the typo of properly being valued. I certify that the appraisal loos were not based on a percentage of the nppmisod propel ly
<br />value. Furthermore, I understand that a fosse or fraudulent overstatement of Iho property value as 11o50110nd In Iho qualified appraisal or this Form 8203 may snbinct Inn to
<br />the penalty under section 0701(a) (aiding and abetting Ilia understatement of tax liability). In addition, I understand That a substantial 01 gloss valuation missl0101110111
<br />resulting from the appraisal 01111e value of the properly that I know, or roasonably should know, would bo used In connection with a return or claim lot rotund, may subioct
<br />me to the penally under section 0695A. I affirm That I have not been boned from presenting °victonca of testimony by the Office of Plofosslonai 1lesponsibilily.
<br />Sign 1 1n
<br />Here Slgnaluro T / (. o r rL LC e Dale ► ( 1 I — �,)r
<br />Business ()dross nc u n q room or sumo n Identifying number
<br />LIZ( 0,05 x N. MN. c1z7V/ 9 "
<br />a
<br />City or town, slab, o ZIP code �� C,Ch Nt d t c y)9 Af �S'07.3 �i �1 •!d
<br />Donee Acknowledg/nent —lo be completed by the charitable organization.
<br />This charitable organization acknowledges that It Is a qualified organization under section 170(0) and that it received the donated property as described
<br />In Section 8, Part I, above on the following date Y
<br />Part IV
<br />Furthermore, this organization affirms that In the event It sells, exchanges, or otherwise disposes of the property described 111 Section hi, Part I (or any
<br />portion thereof) within 3 years after the date of receipt, It will filo Form 0202, Donee Information Return, with the IRS and give Iho donor a copy of that
<br />foam. This acknowledgment dons not represent agreement with the claimed fair markol value.
<br />Does the organization Intend to use the property for an unrelated use? ■ L) Yos L-) No
<br />Nome of cheriloble organization �(donee) Employer idontif'cotton number
<br />`ar' LCrf7 L 6uhAj2R
<br />Address lumber, street, and room or suite no.) City or town, Maio, and ZIP code
<br />Aulhorizod signature
<br />n c ( Mae
<br />® melted on no :yomd roper holm 8283 (nov_ 12 •bona)
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