DS-4273 Donor Form - Individual

U.S. Department of State

DONOR FORM - INDIVIDUAL

*OMB APPROVAL NO. 1405-0218
ESTIMATED BURDEN: 5 Minutes
EXPIRATION DATE: 12·31·2017

Date (mm-dd-yyyy)

Ms. Frances Gidez
Gift Funds Coordinator
U.S. Department of State
2201 C Street, NW
Room 74278, M/EDCS
Washington, DC 20520
Dear Ms. Gidez,
I,

have made the following unconditional gift to the U.S. Department of State:

D

Cash (check):

0

In-kind gift: Please describe the item(s) below and then list the value of the contribution (e.g., 2 pieces of American artwork, including the cost
of shipping, valued at $XX.. .).

I would prefer that this gift be used for the following purpose:

Below, please list and describe the nature of your corporate or organizational affiliations and the affiliations maintained by members of your immediate
family -e.g. board membership, directorship, etc.
The following is a list of my affiliations and the affiliations maintained by members of my immediate family:

DS-4273
12-2014

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In the section below, please choose one of the boxes that describe any matters that you or members of your immediate family, or organizations with
which you are affiliated, have pending before the Department of State. Please also list and describe matters likely to arise before the Department of
State that would substantially affect you or members of your immediate family.

I have no business pending before the Department of State and/or no matters are likely to arise that might involve the Department of State.

I have the following business pending before the Department of State and/or the following matters are likely to arise that might involve the
Department of State:

Name

Signature

Address (for your tax purposes/acknowledgment of your gift)

Privacy Act Statement and Paperwork Reduction Act Statement
AUTHORITIES: The information is sought pursuant to: (1) Foreign Service Buildings Act of 1926, Sec. 9, as amended (22 U.S.C. 300); (2) State
Department Basic Authorities Act of 1956, Sec. 25, as amended (22 U.S.C. 2697); (3) Foreign Gifts and Decorations Act, as amended (5 U.S.C. 7342
and 22 CFR 3); (4) Mutual Educational and Cultural Exchange Act, Sec. 105(f), as amended (22 U.S.C. 2455(f)).
PURPOSE: The principal purpose of gathering this information is to maintain a record of Gift Fund donations and to demonstrate the donor's intention
to donate either an in-kind gift or monetary gift.
ROUTINE USE: The information on this form may include details regarding the type of donation. The form is not distributed to any entity outside the
Department of State. However, information may be reported to Congress if requested.
DISCLOSURE: Providing this information is voluntary. However, failure to provide the information requested on this form may result in the following:
misallocation of an accepted donation; excessive delay in receiving the donation; or return of the donation to the donor.

Public reporting burden for this collection of information is estimated to average 5 minutes per response, including time required for
searching existing data sources, gathering the necessary documentation, providing the information and/or documents required, and
reviewing the final collection. You do not have to supply this information unless this collection displays a currently valid OMB control
number. If you have comments on the accuracy of this burden estimate and/or recommendations for reducing it, please send them to:
M/EDCS, U.S. Department of State, 2201 C Street NW., HST, Room 74278, Washington, DC 20520, Fax: (202) 647-8194.
DS-4273

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