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.