University-Gift-In-Kind-Form 6.08.2021

Gift-in-Kind Form Donor Name: _ Contact Name (if organization representative): _ Address: _ Phone: Email: _ Tax ID or Social Security No.: _ Recipient Unit: _ Contact Name in Recipient Unit: _ Address: _| _ Phone: Email: Description of Gift-in-Kind: _ Intended use of Gift-in-Kind: Location on/off campus of Gift-in-Kind: _ If new product, documentation from donor of value included?  Yes  No If used product, independent third party appraisal completed?  Yes  No Overall Appraised or Market Value: $ _ Please attach itemized appraisal or market value documentation Donor: I, the undersigned, hereby absolutely, irrevocably and without restriction give, transfer, and assign to Stony Brook University all rights, titles, and interests in, to, and associated with the gift-in-kind described above I affirm that I own said object and that to the best of my knowledge I have good and complete right, title, and interests to give _ Print Name _ Signature Date Faculty Member: I, the undersigned, have assessed the gift- or gifts-in-kind referenced above and hereby state that these items have educational, research, or clinical value to my unit If accepted by Stony Brook University, the gift- or gifts-in-kind will be used to advance the university’s mission _ Print Name _ Signature Date Dean or Provost: On behalf of School or College _, I endorse the acceptance of the gift- or gifts-in-kind referenced above _ Print Name _ Signature Once completed, please forward this form and supporting documentation to: Central Services Property Control Office Stony Brook University 100 Nicolls Road Stony Brook, NY 11794-6950 P: (631) 632-6348 E: louise.melious@stonybrook.edu Date