FLORIDA STATE COLLEGE FOUNDATION, INC. RESTRICTED ACCOUNTS FUNDING REQUEST FORM Please-complete the following information and submit to the Foundation for processin Program/event: Chick, Foundes iva, ; Date of Program: Place: RECE ; Poreae reece a Participants: ro) Fou Benefit to College: wily ele trons ARR RT How many students directly benefit from this expenditure’ Payable to: Gi Pick up check Requester reveals Date_W-QI-( ‘This funding request is justified, and I approve this payment out of the Cmansy St account, # 2. x 2 Fund, en's. on few ~ Date nat a OK to fer 4-QI-ll bl Campus President's Signature (F over S1000)() Date oe. ae FOR FOUNDATION USE ONLY Check Date: } i: 2 Check Number: AH‘ mie Authorized by: Date eee Authorized by: Date: 29. Vendor Number: cot. Number: OL O31 CD. O1 5aD 5ak5_ Account Tie: (DAVIN St WL canna ayia) ata PLEASE FORWARD COMPLETED FORM TO FOUNDATION OFFICE SEE REVERSE SIDE OF FORMof Jacksonville cate: FLORIDA'S FIBST CLUE The Rotary Club r ary ROTARY CHARITY FOUNDATION CENTENNIAL GIFT CONTRIBUTION FORM Donor Name: | melee ( Drolhce Date:_4HAY-\U Signature: Address: SO\_\x) Stake Street City: i RESON a NN eeesceeceesesteseeee StateL__ Zip: 32023 Rotary Club of Donor: — yAenuienon. BEES Eee eter estat Pledges to the Rotary Charity Foundation Centennial Gift may be paid over three (3) years. Payments may be charged to your Rotary account or paid by check, or transfer of stock. Pledge Amount: $5, OOO 2011 Paymen:$ 2, JOO 2012 Payment:$_/ » OOC 2013 Payment: $ My gift will be matched: eae Muted ong: METHOD OF PAYMENT: (check appropriate box) * Payment by Rotary Billing: Please charge S_ per quarter to my Rotary account. or * Payment by Check: Make check(s) payable to Rotary Charity Foundation Centennial Gift and mail to 9127 Ft. Caroline Road, Jacksonville, FL_ 32225. or Payment by Check: Please contact Miriam at the Rotary Club of Jacksonville (904-353-6789) to arrange the transfer. ‘Your support of Rotary’s Centennial Gift is greatly appreciated - thank you,INVOICE NUMBER DATE (DESCRIPTION "AMOUNT DISCOUNT _ | NETAMOUNT 47212011 | 2011 gift rom Dr. Steven Wallace $2,000.00 30.00 | $2,000.00 5 5,000.00 80.00 | $2,000.00 FLORIDA STATE COLLEGE sachSOHNLS OMIA 13499 FOUNDATION, INC. Ssssepese cece 501 West State Street CHECK DATE _|_GHECKNO Frown Surecouce _Jakeon, FL Sz 6/12/2011 13499 [__ CHECK AMOUNT “Two thousand and 00/100 Dotlars** PAY $** 2,000.00 10. ROTARY CHARITY FOUNDATION CENTENNIAL GIFT THE, 9127 FT. CAROLINE ROAD or JACKSONVILLE, FL 32225 -D SGNATURE, 013 1, 73.4 HSS