David Ripley Memorial Fund
OMB Control No. 0420-0564
Expires August 31, 2025
(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.
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.
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)