1. Contact Information

2. If the gift annuity is for two people please provide:

3. If the gift annuity is not for you or a spouse please provide the name and date of birth of that person or persons:

First Name
Last Name
Date of Birth January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1900190119021903190419051906190719081909191019111912191319141915191619171918191919201921192219231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008

4. If the gift annuity is to be funded with cash please state the amount:

Cash Amount

5.If the gift annuity is to be funded with publicly traded securities, please state the estimated fair market value:

Fair Market Value
Cost Basis

If you are not certain as to the exact cost basis please estimate:

Estimate

6.If the asset being considered to fund the gift annuity is other than cash or publicly traded securities please state what the nature of the asset and your email or telephone number. You will be contacted to learn more about the asset and the goals you’re you are trying to achieve.

Asset Type
Telephone Number
Email Address

7. Your estimated rate of federal tax rate

Estimate Tax Rate %

8. If your state of residence is out side of California, please name the state

State Select... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming