The University of Texas Health Science Center at Houston Cash Receipt Deposit Form

This form must be attached to all gift checks being sent to the Development Office for deposit. Forms generated by the departments will not be accepted. This information will expedite the gift process and ensure the accuracy of the acknowledgement to the donor. If you have any questions regarding the content of this form, please call Sally Heisler-Anderwald at (713) 500-3075.

TO: Development Office, UCT 12th floor, Attention: Sally Heisler-Anderwald

Date:
From:
Phone:
Title:
Department:
Amount:
Date of Check:
Purpose of Gift:
Check Payor (if different from donor):
Select the category that best describes this gift:	Gift Note: Gifts of a least $1,000 will be acknowledged by the dean or vice president of development. Gifts of $25,000+ will be acknowledged by Dr. Willerson.
	Department-specific gift procured by department faculty/staff (e.g. C.M.E.; education/research gifts; unrestricted departmental funds; sponsorships, etc.) Note: Clinical departments are responsible for thank you letter to donor.
	Honorarium (No thank you letter needed)
	Award/Prize (No thank you letter needed)
Deposit to:
Account Number:

To set up a new account, see New Accounts Set-up Procedure and Request.

Donor Information: Include contact name and address for gifts that require thank you letters. Letters to corporations must have a person's contact name listed.
Contact Name:
Company Name (If Applicable)
Full Address(Street, City, State and Zip code):
Comments:

The University of Texas Health Science Center at Houston