In-Kind Donation Form

Donor Name (Company or Individual)

Contact Person (To address donation acknowledgement letter to- if not the same as above.)

Email

Phone

Address

Item Donation Information

Name of Item/Package

Please supply a high-resolution image of the item (or logo of the company)

Retail Value ($)

Per IRS standards- A retail value of any hard costs associated with a package MUST be listed, even if part of the package is priceless (like a meet & greet or celebrity experience). If the value exceeds $5,000 a receipt/PO/invoice must be included.

Description: Include quantity and any exciting details and description notes for the item.

Donation Restrictions: State any limitations, special restrictions and expiration date.

Contact for Redemption

Phone/Email

Have you provided an image (300dpi) of the auction item:
YesNo

If your donation is a collectable or piece of memorabilia, it MUST be accompanied by a certificate of authenticity or appraisal.

Artwork Specifications: Please fill this portion out only if you are donating a piece of artwork.

Name of Artist

Title of work

Medium

Dimensions: in inches

Current estimated Value ($)

A certificate of authenticity and/or an appraisal must accompany the donated work.

Please provide gallery, studio, private dealer or previous owner where artwork was purchased and available contact information.

Name

Address

Phone

Email

Method of delivery
I will mail the item/original certificate (Keep Memory Alive - Attn: Anna Robins - 888. W. Bonneville Ave., Las Vegas, NV 89106)KMA has my permission to create a certificatePlease pick up my item (Available for Las Vegas Only - We will follow up to coordinate pick up)Certificate to be emailed for KMA to print out

I'm not ready to commit just yet, but please follow up with me after the 1st of the year.
Yes

Please carefully read the following and acknowledge below

• Upon donation, this item becomes the property of Keep Memory Alive. Such donation may be sold at auction, in Keep Memory Alive’s sole discretion, at various events or platforms.

• Keep Memory Alive will not provide you with the final selling price of your donated item.

• Some donated items may be combined with other donated items to create a larger package.

• Keep Memory Alive did not provide any goods or service in whole or part for the above donation.

• If you intend to claim a tax deduction for a non-cash charitable contribution when the amount of the deduction is $500 or more, IRS Form 8283 may need to be completed. Contact your tax consultant for more information.

• There are specific IRS rules for donations of artwork based on the value of the proposed gift. Please consult a tax professional about your proposed gift of artwork as additional IRS rules apply as the value of your proposed gift increases.

• Keep Memory Alive has my permission to use the supplied image or logo online or in print to accompany the donation listing.

I have read and agree to the Terms Date

All proceeds raised through this donation support patients of Cleveland Clinic Lou Ruvo Center for Brain Health and their families. Your generosity funds our social service programs, research trials and caregiver education for those families battling Alzheimer’s, Huntington’s, Parkinson’s, multiple sclerosis and multiple system atrophy. Thank you for your donation!

Power of Love gala auction items are due March 8th, 2024. Forms received after this date are not guaranteed to appear in the printed program. Please keep a copy of this signed form for your records. Keep Memory Alive is a 501(c)(3) organization. Tax exempt ID number 88-0515534.