1. Contact Information

2. If charitable trust if for two people:

3. If the charitable trust 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 charitable trust is to be funded with cash please state the amount:

Cash Amount

5.If the charitable trust 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 charitable trust is other than cash or publicly traded securities please state what the nature of the asset:

Describe
Fair Market Value
Cost Basis (Estimate OK)

7. If the asset is real property, is there debt and how much?

Yes No

Debt Amount

8. Your estimated rate of federal tax rate

Estimate Tax Rate %

9. Select the percentage of income you woul dlike to see illustrated in this example:

5%
6%
7%
8%

10. By providing your email address, we will be able to send the illustration directly to you

Email Address

11. If you would you like us to send a copy of this illustration to your professional advisor please provide:

Name
Email
Phone

If you only know the telephone number and name we will be glad to look up the email address and forward the illustration.