Your Name____________________________ Charity_____________________________
Address______________________________ City, St. Zip__________________________
Telephone_____________________________ Date of Donation______________________
| Quantity | _and | Condition | Quantity | _and | Condition | ||
| Description | Good | Fair ___ | Poor | Description | Good | Fair ___ | Poor |
| Men's Clothing | Boy's Clothing | ||||||
| Dress Shirt | ___ | ___ | ___ | Dress Shirt | ___ | ___ | ___ |
| Casual/Sport Shirt | ___ | ___ | ___ | Casual/Sport Shirt | ___ | ___ | ___ |
| Dress Slacks | ___ | ___ | ___ | Dress Slacks | ___ | ___ | ___ |
| Jeans | ___ | ___ | ___ | Jeans | ___ | ___ | ___ |
| Sweater | ___ | ___ | ___ | Sweater | ___ | ___ | ___ |
| Suit (two-piece) | ___ | ___ | ___ | Suit (two-piece) | ___ | ___ | ___ |
| Sport Coat | ___ | ___ | ___ | Sport Coat | ___ | ___ | ___ |
| Dress Shoes | ___ | ___ | ___ | Dress Shoes | ___ | ___ | ___ |
| Casual Shoes | ___ | ___ | ___ | Casual Shoes | ___ | ___ | ___ |
| Neckties | ___ | ___ | ___ | Caps | ___ | ___ | ___ |
| Winter Coat | ___ | ___ | ___ | Winter Coat | ___ | ___ | ___ |
| Women's Clothing | Girl's Clothing | ||||||
| Dress Blouse or Shirt | ___ | ___ | ___ | Dress Blouse or Shirt | ___ | ___ | ___ |
| Casual Blouse or Shirt | ___ | ___ | ___ | Casual Blouse or Shirt | ___ | ___ | ___ |
| Dress Slacks or Skirt | ___ | ___ | ___ | Dress Slacks or Skirt | ___ | ___ | ___ |
| Jeans | ___ | ___ | ___ | Jeans | ___ | ___ | ___ |
| Sweater | ___ | ___ | ___ | Sweater | ___ | ___ | ___ |
| Suit (Skirt and Jacket) | ___ | ___ | ___ | Jumper (dress or casual) | ___ | ___ | ___ |
| Dress Dress | ___ | ___ | ___ | Dress Dress | ___ | ___ | ___ |
| Casual Dress | ___ | ___ | ___ | Casual Dress | ___ | ___ | ___ |
| Dress Shoes | ___ | ___ | ___ | Dress Shoes | ___ | ___ | ___ |
| Casual Shoes | ___ | ___ | ___ | Casual Shoes | ___ | ___ | ___ |
| Winter Coat | ___ | ___ | ___ | Winter Coat | ___ | ___ | ___ |
| Appliances | Furniture | ||||||
| Dryer | ___ | ___ | ___ | Chair | ___ | ___ | ___ |
| Washer | ___ | ___ | ___ | Chest of Drawers | ___ | ___ | ___ |
| Microwave | ___ | ___ | ___ | Desk | ___ | ___ | ___ |
| Range | ___ | ___ | ___ | Dining Room Set | ___ | ___ | ___ |
| Refrigerator | ___ | ___ | ___ | Lamp | ___ | ___ | ___ |
| Coffee Maker | ___ | ___ | ___ | Sofa | ___ | ___ | ___ |
| Toaster | ___ | ___ | ___ | Table | ___ | ___ | ___ |