UNITED CHURCH OF CHRIST OFFICE OF PHILANTHROPY AND ...
UNITED CHURCH OF CHRIST OFFICE OF PHILANTHROPY AND STEWARDSHIP CHARITABLE REMAINDER TRUSTS - APPLICATION FORM
Type of Agreement: [
] Unitrust [ ] Annuity Trust
Payout Rate: 5%
DONOR(S)
1. Name(s) _____________________________________________________________________
2. Address _____________________________________________________________________
City
____________________________________ State
Zip _____________
3. Telephone (
) ______________________________________________________________
4. Social Security Number(s) __________________________________________________________
5. Birth Date(s) _____________________________________________________________________
PERSON(S) TO WHOM LIFE INCOME PAYMENTS ARE TO BE MADE
Single life OR first of two life income beneficiaries
6. Name
_____________________________________________________________________
7. Address _____________________________________________________________________
City
____________________________________ State
Zip ______________
8. Telephone (
)
9. Birthday _______________________________
10. Social Security Number ____________________________________________________________
Second life income beneficiary
11. Name
_____________________________________________________________________
12. Address _____________________________________________________________________
City
State
Zip _____________
13. Telephone (
)
14. Birthday _______________________________
15. Social Security Number ____________________________________________________________
CHARITABLE REMAINDER BENEFICIARIES
16. Legal Name __________________________________________________________________
Address
__________________________________________________________________
Percent of Gift __________________________________________________________________
17. Legal Name __________________________________________________________________
Address
__________________________________________________________________
Percent of Gift __________________________________________________________________
18. Legal Name __________________________________________________________________
Address
__________________________________________________________________
Percent of Gift __________________________________________________________________
CONTINGENT CHARITABLE REMAINDER BENEFICIARY
If you have any concern that the fundamental purpose of your named organization(s) could change, you may name a contingent beneficiary(ies) and describe the contingency.
19. Legal Name Address Percent of Gift Contingency
__________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________
NOTIFICATION OF BENEFICIARIES 20. The Charitable Beneficiary(ies) listed above will be notified of this gift unless we receive
instructions from the donor prior to contract execution that the gift is to remain anonymous.
FORM OF GIFT
21. [ ] Check (please make checks payable to United Church Funds) Amount: $_______________
22. [ ] Securities: Please contact our office for instructions to mail certificates or transfer electronically.
Estimated Value $ ________________________
Company Issuing Stock a. b. c. d.
Certificate No. # of Shares
Cost Basis ___________
Date Acquired ____________ ___________ ___________ ____________
23. Stock certificate(s) sent by Certified Mail to Boston on _______________________________ (date)
Stock power(s) sent by Certified Mail to Boston on _______________________________ (date)
"Book entry" shares transferred by
(broker) on
(date)
REQUEST FOR DIRECT DEPOSIT OF ANNUITY (LIFE INCOME) PAYMENTS
24. Do you wish direct deposit? Yes [ ] No [ ]
If yes, Bank name _______________________________________________________________
Address & Phone _______________________________________________________________
Account Number
Routing Number
[ ] Checking Account
[ ] Savings Account
AUTHORIZATION 25.
Signature of Donor(s)
_________________ Date
[ ] I/we have enclosed a copy of a photo I.D. (driver's license, passport, state I.D., other). [This is now required by law for donors and all recipients of life income, and must be received before a charitable gift contract can be completed.]
Return this Application Form to: Lynne Hansen UCC Office of Philanthropy and Stewardship 700 Prospect Avenue E Cleveland, OH 44115
For additional information: Toll-free phone (800) 846-6822 Direct phone (216) 736-2171 Fax (216) 736-2297 E-mail HANSENL@
12/02/13 crt
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