Form PC-2143 B PC-2143 B Mail-in Donation form

    OMB Control No.: 0420-xxxx

    Expiration date:

I WANT TO SUPPORT PEACE CORPS BY CONTRIBUTING TO A PARTNERSHIP PROJECT.

I would like to support _____________________________ in the amount of:

                        (Project Number, Country Fund, Special Fund)

$25    $50    $100    $200    $______

CHARITABLE CONTRIBUTIONS TO THE PEACE CORPS ARE TAX-DEDUCTABLE

UNDER SECTION 170(C)1 OF THE INTERNAL REVENUE CODE

Donation Method: Credit Card (check one below)     

                __ Visa/Master Card      __ American Express      __ Discover

                Credit Card Number: ____________________________

                Expiration Date (month/year): _________ / _____________

                Name of Card Holder: ____________________________

                Signature of Card Holder: _________________________

                      Check (make check payable to Peace Corps Partnership Program)

First/Last Name: _______________________________ Phone: ____________________

Company/Group: ______________________________    Email: ____________________

Address: _________________________________________________________________

City: _____________________________________ State: __________ Zip: ___________

Signature: ___________________________________________    Date: _______________

      I authorize the Peace Corps to make my name and contact information available to the Volunteer and community I am supporting.

Would you like to make this donation as a gift or for a memorial? Please provide us with the following information:            Gift      Memorial

Memorial or Gift Recipient:

First Name:__________________    Last Name: ___________________________

Address: __________________________________________________________

City: ___________________________ State: ________ Zip: ________________

Comments: ___________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

WE ARE ONLY ABLE TO FUND A PROJECT UP TO THE AMOUNT THAT A VOLUNTEER REQUESTS.

ONCE A PROJECT BECOMES FULLY FUNDED, ANY EXTRA FUNDS WILL BE ALLOCATED TO THE GLOBAL FUND WHERE THEY WILL BE USED TO SUPPORT PARTNERSHIP PROGRAM PROJECTS WORLDWIDE.

BURDEN STATEMENT

Public reporting burden for this collection of information is estimated to average 10 minutes. This estimate includes the time for reviewing instructions and completing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: FOIA Officer, Peace Corps, 1111 20th Street, NW, Washington, DC, 20526 ATTN: PRA (0420-****). Do not return the complete form to this address.

Privacy Act Notice:

The Peace Corps, an agency of the federal government, is required by the Privacy Act of 1974 (5 U.S.C. 552a) to advise you of the following information regarding this collection. The Privacy Act addresses the federal government’s use of certain personal information in agency files.

A. The request for information is authorized by the Peace Corps Act 22 U.S.C. 2501 (a).

B. The information you provide will be used in processing your donation to the Peace Corps.

C. This information may be used for the routine uses described in the Privacy Act, 5 U.S.C. 552a, and the Peace Corps' published Routine Uses, summarized in Peace Corps' System of Records.

D. Provision of the information requested is voluntary. However, failure to provide sufficient information may preclude your consideration for the Peace Corps Partnership Program or other approved agency fundraising program.