(Date)
Gift Funds Coordinator -- Reconstruction of Iraqi Cultural Heritage
Cultural Property Office
U.S. Department of State
301 4th St., SW, Room 334
Washington, D.C. 20547
Dear Ms. Bishop :
(Name of individual(s))________________________ has (have) made the following unconditional gift to the Department of State: (Please list and describe the gift, including approximate value). I (We) would prefer that this gift be used for the following purpose:
The following is a list of my affiliations and the affiliations maintained by
members of my immediate family: (Please list and describe the nature of your
corporate or organizational affiliations and the affiliations maintained by
members of your immediate family (e.g., board membership, directorship).)
I/We have the following business pending before the Department of State and/or the following matters are likely to arise that might involve the Department of State or the Embassy: (Please list and describe any matters that you or members of your immediate family, or organizations with which you are affiliated, have pending before the Department of State. Please also list and describe matters likely to arise before the Department that would substantially affect you or members of your immediate family.)
(Signature)
Name:
Address: