PO Box 498, Newport, WA 99156

Exempt Number 82-0510506

Deposit Amount:____________________ Date:_______________________

Grant/Donor Name:_______________________________________________________

Contact Name:_________________________________Phone:_____________________

Address:________________________________________________________________

City:____________________________State:____________________Zip:____________

Have you given the Donor a Receipt?_________Date of Receipt Given:______________

A. Is the Foundation to take deposits and disburse funds only? Yes_____ No_____

If yes, complete the following:

Name of Person(s) who may authorize disbursements:

Print Name Signature BCHI Chapter

Print Name Signature BCHI Chapter

******************

Yes______ No______

If yes, please attach a copy of the Grant/Donation with its terms and conditions.

BCHI Chapter Representative:_____________________________________________

Print Name Chapter Name

Address:_______________________________________________________________

City:______________________________State:_________________Zip____________