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<br />AUG 08 '91 11:06 LARKIN, HOFFM8tl_h8HfIR~
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<br />'0'"' 8283 (R.", 3.90)
<br />Naml(t) shown on your Incornl lal IIb1rn
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<br />"Fr:Ft VF: n JUt ~ 9 199,.
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<br />Pa.t 2
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<br />AppraIsal Summary-Include In Section B onl:l items (or groups of $imilar Items) tor which you claimed a
<br />deduction of more than $5,000 per Item or group. (Report contribution! of certai" publicly traded s8curit/!S only
<br />In Section A.) /
<br />If you donated art, you may hlv. to attach the complete appraisal. See the Note In Part I below.
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<br />Informatlan on Oonated Property (To b~ compl,ted b the tax ayer and/orappraissr.)
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<br />1 Check type 01 property:
<br />o Art- (contribution 01 $20,000 or more) . Real E$tate 0 Gems/Jewelry 0 Stamp Collections
<br />o Art- (contribution of less than $20,000) 0 Coin Collections 0 Books 0 Other
<br />· Art Include$ palntlnas, sculpturl', watercolor., prlntJ, drawlnes. ceramics, antlqu. lurnltur., dlcoratlve arts. telltlles, carp Its, sliver. rare manuscripts,
<br />hlstoricll memo,abllla, and othe, slmUar ob/lets. Notet If you don'tld ,rt ,fl'f O.c.mb.r 31, J 987, .nd yoUf tot" ,rt contribUlion deduction "''' $20,000
<br />Dr mor.. you must 'tt'ch . compl.t, copy 0/ the "Ined 'PPfIIl"" S,. InstructIons.
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<br />(I) O"CllptlOn 01 clOII.ted p'Optrty (.It.~" I
<br />.'p'"II.heet II mot. SP"CII, n~td)
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<br />(b) "tll\lllll. prop.,ty wlllt don.ted, &1ft I brl., summa,., of
<br />III, _.11 physlQJ cOl1dltlon at Ih. tlm. 01 tn. &ift
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<br />(c) Appt1lted tilt m.rkel
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<br />(d) OII..cqulr.cI
<br />bl'dOnOt(mo., yr.)
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<br />(I) How acquired
<br />bVdOIlclf
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<br />(f) Canor's cost or (I) 'or b....I" Slru slUt,
<br />adlulted basi. . 8/6/S8, .nttUIMunt recelvtd II'!)
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<br />Taxpayer (Donor) statement-Ust any Item(s) Included In Part I above that Is (are) separately Identified In the
<br />appraisal as having a value of ~500 or less. See I~Btructlons. ,
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<br />I dfl(l.re thlt thelollowinlltlm(.) Included In Pitt I above h., (have) to thl bllt of mv knowlidle and b.lllt an appraised vatu. 01 not mor. tllan $1$00 (per
<br />Item), (ElIter Id.ntifylrr, I.Her from P." I ,nd dHcrib. th. sp~nt: It.m;.
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<br />b.te ..
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<br />rafs., (To be com leted by the, raiser of the above donated (0 efty,
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<br />I d~ar. thet I am not the donor, lh. don.., a perty to the transaction In which tII. donor Icqulted th. property. employ.cl by, marrIed to, or r.lated to any of
<br />th. loreaolna person., or an appr.i..r reCularly us.cl by eny of thl toreloirll plrsona and w"o rlai, not perlorm a malority a' apprals.,s durlnc the taxabll
<br />r*1f 'or other personl.
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<br />Alia, I de<lll" thlt I hold myself out to the pUblic lS.n eppralser or perlor", ,ppl'1llsals an I rtaU"r ba.ls: and that b~us. 01 my qUllitic.tlons.s dlll;rlbed
<br />. In the .pprai.al, lem qualified to make 'PPl'1Ilql4 of th. tYpe of p,op.rty belrll nluttd. I c.rtlfy that the ,,,pfllnl ttee were not b.sed upon a perc.nt..1 01
<br />the .ppralsld propeJty V'/UI. Futthermorl. I und'f*tand lhat . te'" or tfludulent CMrstttemlnt ot the property value is ducrlbtd In the qUIUflld
<br />appraisal Or Ihls ,pp"laal Summary mav subfect the civil penalty under I.c:tlan 6701(8) (Illdlnland .tleltlnl thl understatemlnt of lu lIallility). I
<br />'''''m Ih.t I haYI not bun ba,ted Irom pflS tl evld ne. or testimony by the Dirmor at Practice.
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<br />City or town, Sfllt. .and ZIP ~04'
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<br />65 If '3.S'
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<br />Donee Acknowledgment To be COm leted b the charitable or. lInization.)
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<br />this charitable organization acknowledles that It Is a qualified organltatlon under sectlon 170(c:) and that It received the donated property
<br />as de8c:;ribed In Part I on
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<br />(Oall)
<br />furthermore, this organIzatIon affirms that In the event It $8lis, ellehanges. or otherwise disposes of the propoarty (or any portion thereof)
<br />within 2 years after the date of receipt, It Will file 8nlnformatlon return (Form 8282, Donee Information Ratulr.) with the IRS and lurnish
<br />the donor a coPy of that return. Thi$lcknawledament does not represent concurrence in the claimed (air market '!alul.
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<br />Nama 01 enalll.ot. orlan/Duon (dOntt'
<br />CITY OF ELK RIVER
<br />Adel,u. (number anll m"l)
<br />720 DODGE AVENUE NW
<br />AulllOflltd "811'IU/.
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<br />Employtr idlnUlicallon numb"
<br />41..6005124
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<br />City Of 10WII, lIlli, and ZIP CIKlt
<br />ELK RIVER MN 55330-1900
<br />n~ Olli
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