Application information

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(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

 

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