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F,�m 5283 (Rev. 10 87) Page 2 <br />Narte(s) as shown on your income tax return. (Do not enter name and identification number if shown on the other side.) Identification number <br />Appraisal Summary —Include in Section B only items (or groups of similar items) which have a claimed value of <br />more than $5,000 per item or group. (Report contributions of certain publicly traded securities only in Section A.) <br />If you donated art, you may have to attach the complete appraisal. See the Note in Part II below. <br />UM, Donee Acknowledgment (To be completed by the charitable organization.) <br />.1 This charitable organization acknowledges that it is a qualified organization under section 170(c) and that it received the donated <br />property as described in Part II on _ l� Lt^ ) ' % `d r <br />' (Date) <br />Furthermore, this organization affirms that in the event it sells, exchanges, or otherwise disposes of the property (or any portion <br />thereof) within two years after the date of receipt, it will file an information return (Form 8282, Donee Information Return) with the <br />IRS and furnish the donor a copy of that return. This acknowledgment does not represent concurrence in the claimed fair market <br />value. <br />er and street City ortown, state. and ZIP code _ <br />ruled signature Title % Date <br />c <br />2 Check type of Iffoperty: <br />❑ Art• valued at $20,000 or more ❑ Real Estate ❑ Gems/Jewelry ❑ Stamp Collections <br />❑ Art' valued at less than $20,000 ❑ Coin Collections ❑ Books ® Other <br />'Art includes paintings, sculptures, watercolors, prints, drawings, ceramics, antique furniture, decorative arts, textiles, carpets, silver, rare manuscripts, <br />historical memorabilia, and other similar objects. Note: fn: art with an aggregate value of $20,000 or more ani donated after Oecemb<r 31, 1987. you <br />must attach a complete copy of the signed appraisal and include an 8 x 10 inch color photograph (or a color transparency, no smaller than 4 x 5 inches). <br />These attachments are optional for art donated before lanuary L 19RR. <br />3 (a) Description of donated prom m,(anacha <br />Separate sheet if more space is needed) <br />(b) Date acquired <br />by donor(m0., yr.) <br />(c)Mo. acquired <br />by donor <br />(it) Donor's =1 or <br />adjusted basis <br />I (e)i pprened fair market <br />value <br />A <br />Outdoor Fountain <br />19 0 <br />Purchase <br />3,200 <br />46,000 <br />B <br />C <br />D <br />4 If tangible property was donated, write a brief summary of the overall physical condition of the property at the time of the gift. <br />Outdoor Fountain with all systems in good working order. <br />....................................................................................................... <br />............................................................................................................... <br />............................................................................................................... <br />M Taxpayer (Donor) Statement (To be completed for items listed in Section B, Part 11, with appraised value of $500 <br />or less per item.) <br />I declare that item(s) (enter IeCei,$) identifying property) listed in Part II above has (have) to the best of my knowledge and belief an <br />appraised value of not more than $500 (per item). <br />Sienah:re of taxpayer (durnr)► Date► <br />Certification of Appraiser (To be completed by the appraiser of the above donated property.) <br />I declare that I am not the donor, the donee. a party to the transaction in which the donor acquired the property, employed by or related to any of the <br />foregoing persons, or a person whose relationship to any of the foregoing persons would cause a reasonable person to question my independence as an <br />appraiser. <br />Also, I declare that I hold myself out to the public as an appraiserand that because of my qualifications as described in the appraisal. I am qualified to make <br />appraisals of the type of property being valued. I certify the appraisal fees were not based upon a perentage of the appraised properly value. Furthermore. I <br />understand that a false or fraudulent overtatement of the property value as described in the qualified appraisal or this appraisal summary may subject me <br />to the civil penalty under section 6701(a) (aiding and abetting the understatement of tax liability). I affirm that I have not been barred from presenting <br />evidence or testimony by the Director of Practice. <br />or town, state, <br />Title Dale <br />258 <br />