Charitable Gift Annuity Inquiry Form by yoursovain


									Charitable Gift Annuity Inquiry Form
Please complete this form to request an illustration of the benefits of a charitable gift annuity based on your specific
circumstances. Your illustration will be issued promptly.

First Name: _______________________________                Middle Initial ______     Date: _____________________
Last Name: ____________________________________________________

Address: ______________________________________________________
City, State ZIP: _________________________________________________

         E-mail Address: __________________________________________
         Home Phone: ____________________________________________
         Office Phone: ____________________________________________
         Fax: ___________________________________________________

Affiliation (check all that apply)
              NAS Member
              NAE Member
              IOM Member
              PC Member
              NRC Study Committee Member
              Other (please describe): ___________________________________________

Birthday of Annuitant: __________________________
Birthday of Second Annuitant: ___________________

How would you like to receive your illustration
          Email
          US Mail
Amount of Gift to be used in Gift Annuity Illustration ($10,000 minimum) $_______________

Type of Gift
          Cash
          Stocks or other securities
          Combination of cash/stock/other securities
If stock or other securities will be donated, please provide the following:
Date acquired, if known __________. Cost basis (usually original purchase price), if known $ ___________

To receive additional illustrations, please complete and submit this form for each illustration desired, or call the
Development Office. If you would like to discuss your illustration with a National Academies’ development officer,
please contact the Development Office at 202-334-2431. You may fax your inquiry to us at 202.334.2229, or mail it
to the following address -

                                            Office of Development
                                            National Academies (NAS 073)
                                            500 Fifth Street NW
                                            Washington, DC 20001

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