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Annuity No. (1)
Charitable Deferred Gift Annuity Agreement
(2)
Separate Property Annuity For (3)
This Two 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, to show (11) desire to support 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, with fair market value of $ (12) .
2. Payment of Annuity. In consideration of the property transferred by the Donor, the Charitable Organization shall pay to (13) (hereafter the First Annuitant) for (14) life an annual annuity of $ (15) , in equal (16) payments of $ (17) at the end of each period. If (18) (hereafter the Second Annuitant) survives the First Annuitant, the Charitable Organization shall pay this annuity to the Second Annuitant for life. The first payment shall be on (19) and all future payments shall be one (20) thereafter. If neither Annuitant survives to the date of first payment, the Charitable Organization shall have no obligation to make payments. 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 last to die of the First Annuitant and of the Second Annuitant.
3. Birth Dates, Ages, Social Security Numbers and Addresses. The birth date, age to the nearest year, social security number and address of (21) are (22) , age (23) , SSN (24) and (25) , (26) , (27) (28) . Those of (29) are (30) , age (31) , SSN (32) and (33) , (34) , (35) (36) . 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, if the Donor is the First Annuitant, (37) reserves the right by Will to revoke the Second Annuitant's annuity interest in the Property specified in Attachment A. If a Donor exercises this right of revocation, the Charitable Organization's obligation to make annuity payments shall terminate with the payment prior to the death of the 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 (38) .
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 (39) .
IN WITNESS WHEREOF, the Charitable Organization and the Donor have executed this Agreement on the date stated below.
Donor:
_________________________________ Date: __________________
(40)
(41) Incorporation Date -- (42)
By: _____________________________ Date: __________________
(43) , (44)
Attest: __________________________ Date: __________________
(45) , (46)
KEY
1. Charity's Annuity Number
2. Charity Name
3. Names of Annuitants (persons 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 Name/Annuitant 1 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. Annuitant 2 Name
19. Date of First Payment
20. Period (year, half-year, quarter, month)
21. Donor/Annuitant 1 Name
22. Donor/Annuitant 1 Birthdate
23. Donor/Annuitant 1 Age
24. Donor/Annuitant 1 SSN
25. Donor/Annuitant 1 Street Address
26. Donor/Annuitant 1 City
27. Donor/Annuitant 1 State
28. Donor/Annuitant 1 Zip Code
29. Annuitant 2 Name
30. Annuitant 2 Birthdate
31. Annuitant 2 Age
32. Annuitant 2 SSN
33. Annuitant 2 Street Address
34. Annuitant 2 City
35. Annuitant 2 State
36. Annuitant 2 Zip Code
37. "He" or "she"
38. State in which annuity issued
39. State in which annuity issued
40. Donor/Annuitant 1 Name
41. Charity Name
42. Charity Incorporation Date
43. Charity Director/Officer Name
44. Charity Director/Officer Title
45. Witness Name
46. Witness Title
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