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Annuity No. (1)
Charitable Deferred Gift Annuity Agreement
(2)
Joint Property Annuity For (3)
This Two Life Agreement is made (4) between (5) and (6) of (7) , (8) , (9) (10) , (hereafter the "Donors") and a qualified exempt charitable organization, known as the (11) , (12) , (13) , (14) (15) (hereafter the "Charitable Organization").
1. Property Transfer. The Donors, to show their desire to support the Charitable Organization and to make a charitable gift, have this day contributed to the Charitable Organization the property described in Schedule A attached hereto, with fair market value of $ (16) .
2. Payment of Annuity. In consideration of the property transferred by the Donors, the Charitable Organization shall pay as of the starting date specified below to the Annuitants (17) for their joint lives and to the survivor for his or her life an annual annuity of $ (18) , in equal (19) payments of $ (20) at the end of each period. The first payment shall be on (21) and all future payments shall be one (22) thereafter. If neither Annuitant survives to the date of first payment, the Charitable Organization shall have no obligation to make payments. In addition, the obligation of the Charitable Organization to make the annuity payments shall terminate either without payment if both Annuitants die before the first payment or with the payment prior to the death of the surviving Annuitant.
3. Birth Dates, Ages, Social Security Numbers and Addresses. The birth date, age to the nearest year, social security number and address of (23) are (24) , age (25) , SSN (26) and (27) , (28) , (29) (30) . Those of (31) are (32) , age (33) , (34) and (35) , (36) , (37) (38) . 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 Annuitants 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. Notwithstanding other provisions, Donors reserve the right by Will to revoke the survivor's annuity interest in each Donor's one-half interest in the Property specified in Attachment A. If a Donor exercises this right of revocation, the Charitable Organization's obligation with respect to that one-half interest shall terminate with the payment prior to the death of the deceased Donor. 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 annuitants' 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 (39) .
This annuity agreement shall be interpreted in a manner that is in compliance with applicable existing state law. By signing this agreement, the Donors acknowledge 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 (40) .
IN WITNESS WHEREOF, the Charitable Organization and the Donors have executed this Agreement on the date first stated above.
Donor:
_________________________________ Date: __________________
(41)
_________________________________ Date: __________________
(42)
(43) Incorporation Date -- (44)
By: _____________________________ Date: __________________
(45) , (46)
Attest: __________________________ Date: __________________
(47) , (48)
KEY
1. Charity's Annuity Number
2. Charity Name
3. Donor 1 and 2 Names
4. Date
5. Donor 1 Name
6. Donor 2 Name
7. Street Address
8. City
9. State
10. Zip Code
11. Charity Name
12. Street Address
13. City
14. State
15. Zip Code
16. Property Value
17. Donor Names
18. Value of Annual Annuity
19. Type of Period (annual, semiannual, quarterly, monthly)
20. Payment Amount for Each Period
21. Date of First Payment
22. Period (year, half-year, quarter, month)
23. Donor 1 Name
24. Donor 1 Birthdate
25. Donor 1 Age
26. Donor 1 SSN
27. Donor 1 Street Address
28. Donor 1 City
29. Donor 1 State
30. Donor 1 Zip Code
31. Donor 2 Name
32. Donor 2 Birthdate
33. Donor 2 Age
34. Donor 2 SSN
35. Donor 2 Street Address
36. Donor 2 City
37. Donor 2 State
38. Donor 2 Zip Code
39. State in which annuity issued
40. State in which annuity issued
41. Donor 1 Name
42. Donor 2 Name
43. Charity Name
44. Charity Incorporation Date
45. Charity Director/Officer Name
46. Charity Director/Officer Title
47. Witness Name
48. Witness Title
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