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Form 0203 (Rev. 122000) logo 2
<br />mimes) shown on your income lax return i Identifying number
<br />Soctlon 8. Donated Properly Over $5,000 (Except Certain Publicly Traded Socurities)-- List 111 Ihis section only 8 orris (or groups of similar
<br />items) for which you claimed a (Induction of more than $5,000 por Rom or group (except conlribu(Ion of cer lain publicly it at led
<br />securities reported In Section A). An appralsnl Is generally Iequirod for proporly listed In Section 0 (.son iusl( tic'Ions).
<br />Information on Donated Property t;o be completed by the taxpayer and /or the appraiser.
<br />4 Check the box that describes the typo of proporly donated:
<br />0 Art' (contribution of $20,000 or more) (. -] qualified Gonsorvalion Contribution
<br />❑ Art' (contribution of toss than $20,000) [_] Olhor neat Palate
<br />0 Collectibles" (_] 1, ellaclual Pl oporty
<br />'Art Includes pnlnllnes, sculptures, watercolors. minis. drawings. cnrenlics. 0,11111'0^., decor of ivo arts. 1nxll1es, carpels, slly,
<br />other similar oblecls.
<br />'CollectIbios Include coins, stamps, books, gems, lownlry, spoils womornbllln, dolls, elm, but not art as cleaned above
<br />Not e. In certain cases, you must 0)lach.n q(13111es] np(,r0(srd of the proporly. Soo instrucllans,
<br />(b) 11 ImgQblo properly was donated, give n brief summary of Um over nil (c( Appgricotl Inlr
<br />physicel condition ol the pommy nt the time of lila gilt Inn,knl vnipa
<br />070 .a -. y._L>12c't/. '1 3.J. . ._ _.. _j'_ /1�.Ci.' %�.. CYO.
<br />,Part ,I
<br />5
<br />A
<br />8
<br />c
<br />D
<br />(n( eoscripllon of 11011010(1 proporly (If you 110011
<br />1110re space, 011och n separate slnlemnnl)
<br />(t) Oslo acquired
<br />by donor (mo., yr.(
<br />L.'. Equipment
<br />[.]
<br />seem 'ties
<br />(_ Olbnr
<br />0 1110. Iasiedcai memorabilia, nod
<br />OA s.
<br />(o) I law acquired (r) (boor's cost or
<br />by donor rut/ester) basis
<br />Part II
<br />u bnegnin snlnn, enlur Soo innbucllons
<br />._. 1111 Amount cialno( us n... .
<br />enamor received (i{ Awn ago coding f nor
<br />deduction of seem Alen
<br />Taxpayer (Donor) Statement —List each item Included in P u't I ). bove that the appraisal identifies as 'riving
<br />a value of $500 or less. See instructions.
<br />I declare that the following I1orn(s) included In Pad 1 above Cllr 10 the bos1 of my knowledge and belief an appralrod value of not afore 111011 $500
<br />(per Item). Ent or identifying letter from Part I and (Inscribe the specific awn. Soo lnslruclions.
<br />SI
<br />at of taxpayer (donor) > Dale In
<br />Declaration of Appraiser
<br />I declare that I am not the donor, rho doneo, a parry to Iho transaction In which the donor acquired the proporly, employed by, or related to any of the foregoing persons. or
<br />mmriod to any person who is rotated lo any of (ho foregoing persons. And, it rogulady used by Iha donor, donne, or puny to Iho transaction, 1 performed the majority of my
<br />appraisals during my lax year for other parsons.
<br />Also, 1 declare that I hold myself out to Iho public es an appraiser or portorm appraisals on a regular basis; and Mal bocauso of my qualiacaliorp as described to Iha
<br />appraisal, I am qualified to make appraisals of the typo of properly being valued. I ca l(fy that the appraisal loos worn not based on a percentage of the appraised properly
<br />value. Furthermore, I understand that o !also or fraudulent overstatement of Info property vet o° as doscibod In Iho qualified appraisal or (11(0 rorn! 8203 may 01111(001 ran to
<br />the penally under section 670((e) (aiding and aborting Imo undersialonlont of lax liability). In addition, I understand that a substantial or gross valuation missialm,•nnt
<br />resulting from the appraisal or the yokel of Iho proporly that 1 know, or roasonably should know, would bo used In colorcllon with a return or claim for refund, may suhiecl
<br />mo to gm penally under section 6695A. I nfliml that, harm not loon barred 11o,,, piosonling evidence cs testimony try Iho Office of ('mlossional Responsibility.
<br />Sign �Q�
<br />Here Signature �U � $-- rive of Y i 7 _O " y — -- O �y
<br />r ( / / t Date / 1
<br />Business address (includtr g room or suite 110 I.
<br />!' -- -'- - - --
<br />�'f Identifying number
<br />Clay or town, stole, and ZIP code -- - - --
<br />SC.a.Nd, I'I'iN (.)-(0-)7 _ c0-J3 An? .`kl
<br />Donee Acknowledgmerit —To be completed by the charitable organization.
<br />This charitable organization acknowledges that It la a qualified organization under socllon 170(c) and that it rocoivod (ho dona(od property as described
<br />In Section 8, Part 1, above on the following dale P
<br />Furthermore, this organization al firms that In the event II sells, oxchangos, or otherwise disposes of the property describe(' ' in Section 0, Part I (or soy
<br />portlon thereof) within 3 years alter the dale of receipt, 11 will filo Form 8202, Donee Information Violurn, with the MS and give the donor a copy of tint
<br />torn). This acknowledgment dons not represent agreement with the claimed lair market value.
<br />Does the organization Intend to use the proporly for an unrelated uso9 s Li Yos [1 No
<br />Nome ol charitable organization (donee)
<br />/ Employer 100011(1onllon number
<br />Cruz- 0I' Lt'L7-1.-Fi (..4 A/A 0 it-
<br />Address {number, street, and room or sully no.)
<br />Part, III
<br />Part IV
<br />City or town, slate, end ZIP codo
<br />Authorized signature
<br />Title
<br />note
<br />® Pr /Mod on no roroo Po,mr yowl 8283 (env. 12 -201)0)
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