R-3400 (1/16)
Certification of Donation or Contribution of
Property of a Sophisticated and Technological Nature
A copy of the completed form must be attached to your Individual Income Tax or Corporation Income Tax Return.
Donor
Name of Taxpayer/Entity
Name of Taxpayer’s spouse (if joint individual income tax return)
Address
City
State
ZIP
Telephone
Educational Institution
Name of Educational Institution
Address
City
State
ZIP
Telephone
Description of Donation or Contribution
Value of the donation or contribution $ ___________________
If new property, attach invoice. If used property, appraisal must be obtained from the institution accepting the donation.
Date the donation or contribution was accepted _______________________________________________________
I certify that the value shown is the correct appraisal value of the property described above.
Authorized signature, institution accepting the donation
Date
(mm/dd/yyyy)
The donation or contribution described above was approved and accepted by the board of jurisdiction charged with the
supervision and management of the educational institution shown above. This property shall be used only for the purposes
of research, research training, or direct education of students as specified in La. Revised Statutes 47:37 and 47:287.755.
Authorized signature for the Board of Jurisdiction
Date
(mm/dd/yyyy)
I certify that the property described above has been donated or contributed to the educational institution shown. The donor
shown above does not arbitrarily, capriciously, or unreasonably discriminate against any person because of race, religion,
ideas, beliefs, affiliations, age, sex, culture, physical condition, or political ideas or affiliations.
Authorized signature for the donor
Date
(mm/dd/yyyy)
The donor must attached a copy of the completed certificate their tax return. The educational institution should
keep a copy for their records.