Health Volunteers Overseas

Financial Contribution Form

This is HVO's on-line financial contribution form. Please complete this form and submit on-line upon returning from your volunteer assignment. If you would like a hard copy of this form, consult “Etc” the supplementary CD-Rom that came with your Guide to Volunteering Overseas or contact the HVO office (202) 296-0928.

Name *
Email *
Mailing Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Country of Service *
Date of Arrival *
Date of Departure *
# of Professional Service Days 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
Air Fare $ Dollars
In-Country Travel (e.g. rail, auto, bus) $ Dollars
Food & Lodging $ Dollars
Incidentals $ Dollars
(passport/visa, entry/exit tax, vaccinations, etc.)
Communications $ Dollars
(telephone calls, faxes, etc.)
Subtotal $ Dollars
Other Items
1 $ Dollars
2 $ Dollars
Subtotal $ Dollars
Supplies/Equipment
1 $ Dollars
2 $ Dollars
3 $ Dollars
4 $ Dollars
5 $ Dollars
6 $ Dollars
7 $ Dollars
8 $ Dollars
9 $ Dollars
Subtotal $ Dollars
Total $ Dollars
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, if the appropriate information is provided.

Donor's Name and Address	Items	Value

		$ Dollars
		$ Dollars
		$ Dollars
		$ Dollars
		$ Dollars

Health Volunteers Overseas

Financial Contribution Form

INSTRUCTIONS:

Travel & Living Expenses

Other Items

Supplies/Equipment

PART II