HSWAGATA BUDDHA TOOTH RELICS PRESERVATION MUSEUM
RESTRICTED FUND / PROJECT DONATION FORM
Form Code: HSW-F30
Date: ____ / ____ / ______
Form Number: ___________________________
1. DONOR DETAILS
1.1 Donor Name or Organization:
__________________________________________
1.2 Contact Person (if organization):
__________________________________________
1.3 Address:
__________________________________________
__________________________________________
1.4 Phone / Email:
__________________________________________
2. PROJECT DETAILS
2.1 Project Name:
__________________________________________
2.2 Project Area:
[ ] Relic care / conservation
[ ] Building / renovation
[ ] Education / outreach
[ ] Research
[ ] Other: ________________________________
3. DONATION DETAILS
3.1 Amount Pledged: ___________________________
3.2 Amount Given Now: _________________________
3.3 Currency: _________________________________
3.4 Payment Schedule:
[ ] One-time
[ ] Monthly
[ ] Yearly
[ ] Other: ________________________________
4. CONDITIONS OR RESTRICTIONS
(What must the museum do with this money?)
4.1 Donor’s conditions:
__________________________________________
__________________________________________
4.2 Any limits on how funds may be used:
__________________________________________
5. REPORTING AGREEMENT
5.1 Type of report to donor:
[ ] Simple thank-you letter
[ ] Short financial summary
[ ] Detailed project report
5.2 Reporting Schedule:
[ ] Once at project end
[ ] Yearly
[ ] Other: ________________________________
6. SIGNATURES
Donor / Representative:
Name: ________________________________________
Signature: __________________ Date: ____/____/____
Museum Finance Officer:
Name: ________________________________________
Signature: __________________ Date: ____/____/____
Project Manager (if different):
Name: ________________________________________
Signature: __________________ Date: ____/____/____
