“IRS” Tax Identification Number: 73-1648897
CCN HOUSE
Christ Channel NetworkCharity Donation Authorization Form
Name: ------------------------------------------------------------------------------
Address ---------------------------------------------------------------------------------------
DESCRIPTION OF MERCHANDISE/Goods/Products: ---------------------------------------
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Total Number of Pallets/Cartons/Units Donated: -------------------------------------------------
Fair Market Value: ----------------------------------------------------------
Donor’s Officer Signature: ------------------------------ Printed Name: ---------------------------
Recipient Charity:CCN Community Resource Center
Mailing Address: P.O.Box 13723, Los Angeles, and CA. 90013
1370 E 42ND Street, Los Angeles CA. 90011Contact Person: Emmanuel Tula (310) 259-5526
Inventory list of items: (Attach sheets if necessary).
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Pick-up Driver Signature Print Name Date of Pick-up
All donations are tax deductible, CCN timely submitted reports of its activities and “Schedule B “ donor’s reports with Form 990 to IRS in the last 5 years, 2002-2006.
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