Donor 1 Name

Donor 1 Date of Birth

Social Security Number

Donor 2 Name

Donor 2 Date of Birth

Social Security Number

Company or Foundation (if applicable)

Street Address

City, State, Zip

Telephone

Fax

E-mail

FINANCIAL ADVISOR'S NAME

Financial Advisor's Address

City, State, Zip

Telephone

Fax

E-mail

ACCOUNTANT'S NAME

Accountant's Address

City, State, Zip

Telephone

Fax

E-mail

ATTORNEY'S NAME

Attorney's Address

City, State, Zip

Telephone

Fax

E-mail

Successor Charitable Advisor's Name

(Person appointed to make distribution recommendations if donor(s) are no longer willing or able to.)

Street Address

City, State, Zip

Telephone

Fax

Signature Donor 1

Date

Signature Donor 2

Date