DS-4271 Donor Form - Government

U.S. Department of State

*OMB APPROVAL NO. 1405-0218
ESTIMATED BURDEN: 10 Minutes
EXPIRATION DATE: XX-XX-20XX

DONOR FORM - GOVERNMENT

Date (mm-dd-yyyy)

Gift Funds Coordinator
U.S. Department of State
2201 C Street, NW
Room 1821, CGFS/EDCS
Washington, DC 20520

has made the following unconditional gift to the U.S. Department of State:
(Name of Government/Country)

Cash (check):
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…).
Item Description

Value

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

Below, please choose one of the boxes that describe any matters that you have pending before the U.S. Department of State.

(Country/Government)

has no business pending before the Department of State and no matters are likely to arise

that might involve the Department of State or U.S. Embassy, or the U.S. Consulate.

(Country/Government)

has the following business pending before the U.S. Department of State and or the

following matters are likely to arise that might involve the U.S. Department of State, U.S. Embassy, or the U.S. Consulate:

DS-4271
12-2020

Page 1 of 2

Name

Signature

Title

Point of contact, if different from the name listed from the name
Return Mailing Address for Acknowledgment Purposes

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 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 form is not distributed to any entity outside the Department of State. However, information may be reported to Congress if
requested. More information on the Routine Uses for the system can be found in System of Records Notice, State-80, Official Gift Records and Gift
Donor Vetting Records.
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 10 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:
CGFS/EDCS, U.S. Department of State, 2201 C Street NW., HST, Room 1821, Washington, DC 20520, Fax: (202) 647-8194.

DS-4271

Page 2 of 2