(Minimum funding amount: $10,000.00)
Type of Gift:
Name of Fund/Trust:
Name of Donor(s):
Life Income Beneficiary:
Social Security #:
Account Type (Checking):
Bank Name and Address:
Designation at The First Church of Christ, Scientist:
The Mother Church Endowment Fund.
Type of Asset:
Anticipated Funding Amount:
Mean Market Value:
No other goods or services were provided in consideration for this contribution.
PLEASE REVIEW THESE FIGURES WITH YOUR TAX COUNSEL
By signing this form, you acknowledge that you have received a copy of the Gift Annuity Disclosure Statement.