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Annuity No. (1)
Charitable Deferred Gift Annuity Agreement
(2)
Deferred Gift Annuity For (3)
This One Life Agreement is made (4) between (5) (hereafter the "Donor") and a qualified exempt charitable organization, known as (6) , (7) , (8) , (9) (10) (hereafter the "Charitable Organization").
1. Property Transfer. The Donor, as an evidence of (11) desire to support the work of the Charitable Organization and to make a charitable gift, has this day contributed to the Charitable Organization the property described in Schedule A attached hereto, the fair market value of which is $ (12) .
2. Payment of Annuity. In consideration of the property transferred by the Donor, the Charitable Organization shall pay to the Annuitant (13) for (14) life an annual annuity of $ (15) , in equal (16) payments of $ (17) at the end of each period. The first annuity payment shall be on (18) and all future payments shall be one (19) thereafter. If the Annuitant does not survive to the date of first payment, the Charitable Organization shall have no obligation to make payments. The obligation of the Charitable Organization to make annuity payments shall terminate either without payment if the Annuitant dies before the first payment or with the payment prior to the death of the Annuitant.
3. Birth Date, Age, Social Security Number and Address. The birth date, age to the nearest year, social security number and address of (20) are (21) , age (22) , SSN (23) and (24) , (25) , (26) (27) . If any birth date or age shall be at any time found incorrect, then any underpayment or overpayment due to misstatement or other error, with interest as may be specified in Treasury Regulations, shall be corrected by prompt distribution to the Annuitant or by charge against current or future payments, as may be applicable.
4. Annuity Provisions. This annuity is irrevocable and nonassignable, except that it may be assigned to the Charitable Organization. This Agreement and attached Schedule is the entire agreement.
5. Payout and Use Provisions. Unless the Charitable Organization is notified in writing of a change of address or another method of payment is selected by written agreement, annuity payments shall be made to the annuitant's address noted in this agreement. Annuity payments shall be made under the provisions of this agreement and shall not be otherwise modified or commuted. After all required annuity payments under this agreement are completed, any annuity remainder amount shall be distributed to the Charitable Organization for its general uses and purposes.
6. State Law Provisions. This Agreement shall be governed by the laws of the state of (28) .
This annuity agreement shall be interpreted in a manner that is in compliance with applicable existing state law. By signing this agreement, the Donor acknowledges receipt of the Charitable Organization Gift Annuity Disclosure Statement, in accordance with the requirements of the Philanthropy Protection Act of 1995.
The annuity payments to be made under this gift annuity agreement are backed by the full faith and credit of the issuing organization. [NOTE: Check the state regulations to ensure that no state specific disclosure language is required.]
In addition, to the extent an amendment does not conflict with federal law, the agreement may be amended by mutual agreement of the parties solely for the purpose of compliance with state law, with such amendment subject to approval of the Insurance Commissioner of the State of (29) .
IN WITNESS WHEREOF, the Charitable Organization and the Donor have executed this Agreement on the date stated below.
Donor:
_________________________________ Date: __________________
(30)
(31) Incorporation Date -- (32)
By: _____________________________ Date: __________________
(33) , (34)
Attest: __________________________ Date: __________________
(35) , (36)
KEY
1. Charity�s Annuity Number
2. Charity Name
3. Names of Annuitant (person to receive annuity)
4. Date
5. Donor Name (separate property contributor)
6. Charity Name
7. Street Address
8. City
9. State
10. Zip Code
11. "His" or "her"
12. Property Value
13. Donor/Annuitant Name
14. "His" or "her"
15. Value of Annual Annuity
16. Type of Period (annual, semiannual, quarterly, monthly)
17. Payment Amount for Each Period
18. Date of First Payment
19. Period (year, half-year, quarter, month)
20. Donor/Annuitant 1 Name
21. Donor/Annuitant 1 Birthdate
22. Donor/Annuitant 1 Age
23. Donor/Annuitant 1 SSN
24. Donor/Annuitant 1 Street Address
25. Donor/Annuitant 1 City
26. Donor/Annuitant 1 State
27. Donor/Annuitant 1 Zip Code
28. State in which annuity issued
29. State in which annuity issued
30. Donor/Annuitant 1 Name
31. Charity Name
32. Charity Incorporation Date
33. Charity Director/Officer Name
34. Charity Director/Officer Title
35. Witness Name
36. Witness Title
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