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Social Service Agency Inc. EIN # 45-1599073   
www.HoustonCharityAgency.org

Received from:____________________________________________
(Donors name)

at ______________________________________________________
(Donors Address)

On_________________:
(Date of Contribution)
The following items:

Clothing Items?                ( ) YES   ( ) NO
Furniture?                        ( ) YES   ( ) NO
Appliances                       ( ) YES   ( ) NO
Home Décor                     ( ) YES   ( ) NO
Electronics?                     ( ) YES   ( ) NO
Non-perishable Foods?    ( ) YES   ( ) NO
Monetary Gift?                 ( ) YES   ( ) NO               

Description of items:
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________

Total Donation Value $____________


Social Service Agency Inc.
EIN # 45-1599073
1202 Pasadena BLVD, Pasadena, TX 77502
ELECTRONIC SIGNATURE: Leland Smith
www.houstoncharityagency.org