Yale

SCHOOL OF MEDICINE

YSM Gift Assessment Reduction or Waiver Request

This form is to request a waiver or reduction of the university assessment on gift revenue. The form is valid for up to two years from the date of approval or when the deposit amount has been met, whichever occurs first. Department Business Offices (DBO) are responsible for submitting the approved form to the YSM Controller’s Office at ysmcontroller@yale.edu so that an adjustment can be processed. If the department is directly responsible for rebating the assessment to the gift, please process the adjustment within your DBO. For assistance with COA usage, please contact ysmcontroller@yale.edu.

Deposit Details

Donor Name

Current Amount ($)

Deposit Date

Expected Future Deposits ($)

Gift Revenue COA

This is the COA where gift revenue was/will be deposited.

Waiver Funding COA (if applicable)

This is the non-sponsored COA your department will utilize to cover the amount of the assessment.

Gift Assessment Information

Applicable Assessment % **

0.0 to 100.0 as a decimal.

Rate Being Requested %

0.0 to 100.0 as a decimal.

Explanation/Justification

In the box below, provide an explanation/justification and attach documents as necessary, including but not limited to a copy of the donor’s assessment policy, copy of gift agreement, and copy of budget

Supporting Documents

Requestor Information

Submitter's Name

Submitter's Email

Department

Faculty Name

Status

Request is being processed.