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This form must accompany contribution check. Tax deductible contributions to the Diplomatic Reception Rooms may be made by check to "U.S. Department of State" and mailed to: Office of the Director |
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Please complete either the Individual Donor or Corporate/Foundation Donor portion:
Individual Donor In deciding whether the Department may accept this gift, you must consider whether I (we) have matters pending before the Department. Please be advised that:
I am affiliated with the following corporation and other organizations (please indicate the nature of the affiliation, e.g., member of the board, director, C.E.O.): My spouse is affiliated with the following corporate and other organizations (please indicate the nature of the affiliation, e.g., member of the board, director, C.E.O.): ______________________________________________________________________________
Except as set forth below, neither I, my spouse or any of the corporations or organizations listed above have any matters pending or likely to arise in the future that might involve the Department of State. (Describe pending matters or matters likely to arise.) Corporate or Foundation Donor
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In deciding whether the Department may accept this gift (corporation or organization), you must consider whether I (we) have matters pending before the Department. Please be advised that, except as set forth below neither (the corporate or other entity) or its major subsidiaries and affiliates have any matters pending or likely to arise in the future that might involve the Department of State: (Describe pending matters or matters likely to arise.)
Name (or) Name of Contributing Organization and Responsible Party
Date:_______________ |
IMPORTANT
Contributors of $1,000 or more a year and donors of gifts in kind are entitled to receive an invitation (and may bring a spouse or guest) to the annual reception hosted by The Secretary of State.
Under the Internal Revenue Code as amended in 1993, we are required to inform you that the deductibility of your contribution must be reduced by the value of the reception ($40 per person). You may elect not to receive this information in which case your contribution is fully deductible. Accordingly, please check below if you do not wish to be issued an invitation.
___(Ö ) Amount of Contribution: $_____________________
I wish to receive invitation to the annual reception for donors. Contribution will be reduced by $80 for gifts $1,000 or more.___(Ö ) Amount of Contribution: $_____________________
do not wish to receive an invitation to the annual reception for donors. Contribution will be 100% deductible.
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(Signature)
