CROCKERY LAKE ASSOCIATION
2442 Crockery Shores Road
Casnovia, MI 49318
(616) 887-8707
DONATION FORM FOR INCOME TAX DEDUCTION
Your contribution of materials to Crockery Lake Association is deductible from your income tax return,
as Crockery Lake Association is recognized as a tax-exempt organization under § 503(c)(3) of the Internal
Revenue Code. While we cannot take the responsibility of estimating the dollar value of your contribution,
the government feels you, the contributor, are in the best position to estimate honestly the true value of your
gift. The factors listed below are the ones Internal Revenue authorities have considered applicable.
Contributed by			_______________________		Contribution Date		________________
Address		_____________________________________________________________
Quantity			Name of Article			Original Cost		Fair Market** Condition* When Given		Value When Given
______			____________________			_____________		_________		_________
______			____________________			_____________		_________		_________
______			____________________			_____________		_________		_________
______			____________________			_____________		_________		_________
______			____________________			_____________		_________		_________
______			____________________			_____________		_________		_________
______			____________________			_____________		_________		_________
______			____________________			_____________		_________		_________
______			____________________			_____________		_________		_________
______			____________________			_____________		_________		_________
______			____________________			_____________		_________		_________
______			____________________			_____________		_________		_________
				Page Total		_____________		Page Total		_________
Date _________________				Acknowledgement signature by			__________________________
Crockery Lake Association did not provide any goods or services in exchange for this donation.
Signature of Contributor ________________________________
*		New, Good, Fair, or Poor
**		Indicate how "Fair Market Value" was determined, e.g.: "Half of purchase Price, " "One Third of purchase price," "Appraised figures," "Book value," or other.
NOTE: Additional items can be listed on plain sheets of paper, using the same format to itemize as above. Sign and date all additional sheets and attach.
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