Polk County Public Library
 Special Collections

STATEMENT OF GIFT

I own the materials described below and voluntarily donate them to the Polk County Public Library Special Collections to become its permanent property and to be administered in accordance with established policies. The purpose and intent of this gift is to transfer and assign all rights, title and interest I possess to these materials to the Library, except as specified below. The Library may use its discretion to dispose of material inappropriate for its collections, unless instructions to return unwanted materials to the donor are stated below.

Description of materials:

Restrictions on the use of and/or access to these materials:

                                                                   
_______________________________________________                                                                                                                                                                              

 Signature of Donor or Agent                                    Date

_______________________________________________
Library Director                                                        Date

Donor Name:
                                                                                                                            
Donor Address:
                                                                                                                           
Donor Phone:

Policy Approved by Board of Trustees July 20, 2006

Liz Malloy, chairperson