Form PC-2143 C PC-2143 C Call-in Donation Form

OMB Control No.: 0420-xxxx

Expiration date:

Office of Gifts and Grants Management

DONATION FORM

(Please fill out in blue ink)

INTERNAL PC INFORMATION
PC Staff Name:				Intake Date:
PROJECT/FUND INFORMATION
Project/Fund Name:
Donation Amount: $				Peace Corps Gifts: Signed Artwork Unsigned Artwork	PSA Sticker Other T-Shirt WS WM WL MM ML MXL
Restricted Donation/In Memory of/In Honor of/For HQ or Post (Optional)
Is this donation in memory/honor of someone? Yes, provide name No
Comments:
Name:
Address:				Email:
				Telephone:
I authorize Peace Corps to make my name and contact information available to the family.
I DO NOT authorize Peace Corps to make my name and contact information available to family.
DONOR INFORMATION
Contact Name & Title (Mr., Ms):
RPCV/Country/Date service:
Staff:
Address: (for tax acknowledgement)				Email:
				Telephone - Cell:
				Telephone – Home:
				Telephone – Work:
I authorize Peace Corps to include my name on the Donor Recognition Page of the Peace Corps website.
I DO NOT authorize Peace Corps to include my name on the Donor Recognition Page of the Peace Corps website.
Yes, please keep me informed about Volunteer stories from the field, events, and opportunities to partner with the Peace Corps.
Yes, Peace Corps may contact me for information about my service (for RPCVs), affiliation, and/or gift(s) to the agency.
Peace Corps will not share your information with outside organizations.
PAYMENT INFORMATION
Type of card: VISA MasterCard AMEX Discover
Name as it appears on the credit card:
Card Number:					Expiration Date:

Yes, information has been posted on Donor Items Tracking Log Initial: Date:

Yes, check or credit card info has been received by AO Initial: Date:

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: This information is being collected pursuant to 22 U.S.C. 2501(a). This information will be used in processing your donation to the Peace Corps. Disclosure of this information is voluntary. Failure to provide sufficient information may preclude your consideration for the Peace Corps Partnership Program or other approved agency fundraising program. 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.

Paul D. Coverdell Peace Corps Headquarters

Office of Private Sector Initiatives

1111 20th Street, NW ● Washington, DC 20526

Tel 202.692.2170 ● Fax 202.692.2171● Email [email protected]