Instructions for Completing the "In-Kind" Contribution Form Policy Number and Last Update (01.09.26/01-2011)

  1. Print the name and address of the volunteer or donor. In the small box at the right, place a check mark if the donor is a current or former Head Start parent.
  2. The long column, on the left of the page, contains a box for every day of the month. If a person is volunteering time to the program, write the number of hours worked in each corresponding date.
  3. The wider table on the right side of the page, under "Indicate Services Performed", is to write the name of the actual service. For example:
    1. Admin./Board: board meeting
    2. Medical: 50 physical examinations
    3. Dental: extraction, upper & lower incisors
    4. Mental Health: consultation with teachers
    5. Educ./Classroom: puppet show
    6. Nutrition: review menus
    7. Social Services: translation for WIC application
    8. Parent Involvement: ESL class
    9. Transportation: 4 parents to citizenship classes
    10. Disability Services: audiological evaluation
    11. Other: planting tress and vines on playground, painting building
  4. The bottom part of this table is for writing the rate at which the program values the services. (You must value the work as it would normally be paid.) After "basic", write the rate paid per hour, item, etc. If a service (for example, planting trees) is performed by a lay person, it can only be valued at a general labor rate. The next line, "Value higher due to:" needs to only be completed if you are assigning a value higher than basic rate. For example, if the trees were planted by a professional landscape artist, the rate would be higher than basic. However, if the landscape artist were to install computers in the classroom, his rate would be at the basic skilled labor rate because he is not a professional in that area.
  5. The next line, "Consultant discount," is the amount of discount offered - the consultant's normal rate, less amount charged to Head Start program for services; the difference is the in-kind donated amount.
  6. The small box on the left, "Other goods or space" is for donations to the Head Start program of goods or space - NOT for time or services. Write what the items are, for example, "tomato plants for children's garden"; "April rent for Head Start building"; "meeting room for board meeting"; or "3 goldfish for classroom aquarium". Assign a value to the donations, and briefly explain how that value was determined, for example, "new, retail price"; "depreciated according to schedule", etc. You must make sure that you do not over-value any donation, because an excessive value could be disallowed. If you base a price on current prices in the area, the comparison must be with an item of similar quality and function.
  7. In the box directly to the right, record donations of the use of a private vehicle to transport Head Start children and/or families. Write the number of miles drive, the center's reimbursement rate per mile, and compute the total contribution. (If the driver also donated her time, record those hours in the box above). The reason for the trip, which must be to conduct Head Start business, must also be recorded.
  8. In the last box, write the total amount of the contribution of this individual for this month, including goods and services. Have the donor sign the form.