OMB Control No. 0420-0564
Expires August 31, 2025

Your Information

(So we can send you a tax receipt)

NOTE: We use Pay.gov as our trusted secure payment processor. We’ll send you on to there and bring you back when you finish.

This is a secure transaction

The secure server software (SSL) that processes Peace Corps donations is the industry standard and among the best software available today for secure commerce transactions. It encrypts all of your personal data including credit card number, name, and address, so that it cannot be read as the information travels over the Internet. You can tell when you are protected by encryption — the lock or key at the bottom of your browser changes color or is no longer broken.

Burden statement

Public reporting burden for this collection of information is estimated to average 10 minutes per response. This includes the time for reviewing instructions and completing the information. This is voluntary information collection. An agency may not conduct or sponsor, and persons are 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: the FOIA/Privacy Officer, Peace Corps, 1275 First Street NE, Washington, DC 20526.

Privacy Act statement

The Peace Corps, a U.S. government agency, is required by the Privacy Act of 1974 (5 U.S.C. 552a) to advise you of the following information regarding this form and how we protect personal information that the agency maintains and uses in its systems of records.

Authority: The Peace Corps Act (22 U.S.C. 2501 et seq.), as amended which authorizes the Peace Corps to accept gifts in furtherance of the purposes under the Act.

Purpose: The primary use of the information on this form is to process your financial donation.

Routine Use: Use of the information collected on this form is restricted to the purposes cited in this privacy statement or unless the disclosure is otherwise permitted under the provisions of the Privacy Act of 1974, 5 U.S.C. 552a (b) "Conditions of Disclosure," and the agency’s privacy policy. The information you provide on this form may be shared under the general system of records routine uses A through M that apply to this system. For information on these routine uses, click on the link to the Peace Corps Privacy web page. This information collection is covered by System of Records Notice PC-10, Office of Private Sector Initiatives Database. Your name and donation amount may be disclosed as part of a valid FOIA request to obtain access to donor information collected by the Peace Corps as an independent agency under the Executive branch of the United States government. The agency is committed to ensuring that any personal information it receives is safeguarded against unauthorized disclosure.

Disclosure: Completion of this form is voluntary; however, failure to complete this form may impair or delay the Peace Corps’ ability to process your donation.

PC-2143A (Rev. April 2022)