Financial Contribution Form

 

Name:

Email:

Address:

Division:
Country of Service:
Date of Arrival:
Date of Departure:
No. Days of Professional Service Donated:

INSTRUCTIONS: All expenses incurred directly by you should be listed below. If you took any equipment, supplies or other items donated by companies or individuals, please complete Part II.

Travel & Living Expenses Cost
Air Fare $
In-Country Travel
(rail, auto, bus, etc.)		 $
Food & Lodging $
Incidentals
(passport/visa, entry/exit tax, vaccinations, etc.)		 $
Communications
(telephone calls, faxes, etc.)		 $

Subtotal

$
Other Items Cost
1. $
2. $

Subtotal

$

 

Supplies/Equipment Cost
1. $
2. $
3. $
4. $
5. $
6. $
7. $
8. $
9. $

Subtotal

$
Total $

PART II

Please list all donations of supplies, equipment, and other materials that you received on behalf of HVO for use overseas. In order to comply with IRS and auditing requirements, we ask that you attach an itemized list (a packing list or invoice will suffice) or fill out the section below for all such donations. All donations over $250 will be acknowledged by a letter from HVO/Washington if the appropriate information is provided.

Donor's Name & Address Item(s) Value
1. $
2. $
3. $
4. $
5. $

Submit this form by simply clicking on the button below or print it out and fax or mail the completed form to HVO