ONE Life Charitable Gift Annuity

 

Please complete the following information and push “Submit.”  All information will

remain confidential and will be sent directly to the Director of D&D Gift Planning.


 

 Date:   Mo.        Day       Year     

Annuitant Name

                                                                                                                                             
Address:         Street                                                                             City                                               State            Zip

             


Telephone #:                   Fax #:               E-mail:     

 Date of Birth:       Mo.        Day       Year          
     

Current Dollar Amount of illustration Annuity: $


Tax Bracket:     %


This Charitable Gift Annuity will be Funded By: 
 

If Using Stocks:


Number of Shares to be Transferred:

    (For Dollar amount of Annuity illustration)

 

Current Dollar Value of Shares: $
 

How Titled:
 

Year Purchased: Cost Basis at Purchase:
 

Above Authorized By Annuitant :