(Minimum funding amount: $10,000.00)
Type of Gift:
Name of Fund/Trust:
Name of Donor(s):
Phone Number:
E-mail Address:
Legal Address:
Life Income Beneficiary:
Beneficiary #1:
DOB:
Social Security #:
Legal Address:
Payment Address:
Banking Information:
Account Name:
Account Number:
Routing Number:
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:
Acquisition Date:
Cost Basis:
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.
___________________________________________________ Date_________________
DONOR SIGNATURE
