Donation Receipt Form

 Receipt of OSHC Foundation, Inc. Donations

                                                                                                                                Date: __________

 Organization receiving products, services or funds:

 Name:                   _________________________________________

Address:               _________________________________________

                             _________________________________________

City/Province:        _________________________________________

Country:                _________________________________________

 Description of products, services or funds received:

_____________________________________________________________

 _____________________________________________________________

 _____________________________________________________________

Date(s) delivered: ______________________________________________

 If multiple releases, list amounts and dates received.

Attach any pertinent documentation such as shipping manifest, invoice or letter of receipt.

 Signature of person receiving products, services or funds:

 ________________________________________________________

Signature                                                         Print Name

 Send this form and documentation to:      Jack Hagen

    Treasurer, OSHC Foundation

    1949 Surrey Lane

    Grafton, WI 53024 USA

    Tele/Fax: (262) 377-8238

    E-mail: hagenjg@sbcglobal.net