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Medtronic Time-n-Talent - Part A (to be completed by volunteer:Employee/Retiree/Board Member) <br />VOLUNTEER INFORMATION j �/ <br />Name 1DPrT_YZT_CA-1' f� '- Social Security Number � '—e a _ ( r-� <br />s-o <br />Position/Deppt./Business c�F' 1 <br />Address 7060 C&,vTPru_ hvt-wan- Ah:�::- Mail Stop �7 o <br />City rr�=Iai�y State_ ZIP Code _S 3Z <br />Current Status: Full-time Part-time Retiree Board of Directors <br />RECIPIENT ORGAN)IZ%ATIONj� n n % <br />Name A&,a I LS 1'cth- lCeeirea4-ion i j OT 'tom r' I L5 <br />Address `Y J h k (A A ( t a f'S e_ PGt <br />City 1` &In' State M ZIP Code2- <br />VOLUNTEER SERVICE WITH THIS ORGANIZATION <br />How many volunteer service hours did you provide? ' y h'9tWS A-:, <br />During which months did you provide this service? N,T 7, l <br />Do you serve on the Board or committee of the organization? V Yes No <br />If yes, which oneAFri IL R_rk- _ '►nAee <br />I <br />I authorize the nonprofit named above to report this information to the Medtronic Foundation to qualify <br />for a Time-n-Talent Fund grant and affirm that I have performed the volunteer service listed above within <br />the past 12 months. <br />Signature <br />Wj <br />......................................................................................................................................................................................... <br />Medtronic Time-n-Talent - Part B / D���� <br />(to be completed by an authorized representative of the nonprofit organization) G ,S <br />I hereby confirm that the volunteer service described in Part A of this application has been performed by <br />the above -named volunteer for the number of hours on the dates indicated. I hereby certify further, that <br />in addition to the time commitment, the volunteer contributed <br />$ to this organization on � 19 <br />* Note 1. You must attach a copy of the Internal Revenue Service letter granting 501(c)(3 <br />tax exemption to your organization as verification of your nonprofit status.�� M�Va1gP�h-�� <br />2. In order for a gift to be matched, receipt or proof W <br />be attached. <br />Signature of Authorized Representative <br />Print Name <br />Title U IT <br />Telephone Number <br />CoS0633— �6_74 <br />Please return this form along with a copy of the IRS letter and proof of gift to: /re clft r4Y4v-- <br />The Medtronic Foundation, 7000 Central Avenue NE, Minneapolis, MN 55432 t1 C1 n ort *Oki HILL-5 <br />PWk)HA&j M Oi l/ <br />• <br />