Southwest Alternatives Institute, Inc.

Restricted Gifts Reporting Form

This form must be completed and mailed back to SAI no later than May 15, or as agreed. This a report of all funds spent with money donated through SAI and dispersed to your group for the fiscal year (April 1-March 31). Even if there is no activity with SAI, this form must be completed by all active groups to retain status each year. Attach receipts, as requested. Keep original receipts on file.

Report Period Covered: April 1, _______ through March 31, ______

Group:      __________________________________

Address:      __________________________________

City:      ________________________       State:  _________      Zip: __________

Contact Person: _____________________      Contact Person Phone:  ____________________

RESTRICTED USE

The funds were used for tax-exempt purpose(s) were (check one):    

            EDUCATIONAL     CHARITABLE             MEDICAL            OTHER: ___________________

EXPENSE BUDGET

Please detail expenses totaled for the reporting period:

1. PERSONNEL                                   $ ________

2. FRINGE                              $ ________

3. TRAVEL                        $ ________

4. SPACE/RENTALS                  $ ________

5. CONSUMABLE SUPPLIES            $ ________

6. PRINTING/REPRODUCTION            $ ________

7. EQUIPMENT PURCHASE            $ ________

8. POSTAGE                         $ ________

9. UTILITIES                        $ ________

10. RENT/OVERHEAD                  $ ________

11. ENTERTAINMENT                  $ ________

12. ADMINISTRATION                  $ ________

13. MEDICAL                        $ ________

14. OTHER (specify)                  $ ________

TOTAL AMOUNT SPENT               $ ________

TOTAL AMOUNT UNSPENT (balance)     $ ________

Please write a brief narrative (on back) of how these expenses were used for tax-exempt purpose(s) as indicated above. Attach a copy of all receipts. Mail to SAI, P.O. Box 3355, Tucson, AZ. 85722. If you need help filling out this form, please call 520-623-3733. Thank you

_________________________________            ________________________

Signed by Group Representative                    Date

_________________________________            _________________________

Received by SAI                                                    Date

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