CGADGA Application _PDF_ - Chari

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					                                                   51 Children’s Way • Enterprise, Florida • 32725
                                                               Phone (386) 668-4774


                                       Charitable Gift Annuity Application

I/We apply to The Florida United Methodist Children’s Home, Inc. for an irrevocable charitable gift annuity [ ] single-
life agreement or [ ] two-life agreement, desiring that this gift ultimately be used for the mission and purposes of the
Children’s Home, and as indicated by the ultimate beneficiary designation (if any). I/We understand that this is an
irrevocable agreement and that these funds are completely transferred to the Children’s Home and may not be
withdrawn.

First Life Income Beneficiary (payments are to be made for life to): 
 
Name (Title, First, Middle, Last) ________________________________________________________ Date of Birth ____________________ 
 
Address _________________________________________________ City/State Zip___________________________________________ 
 
Daytime Telephone # _____________________  Email Address __________________________________________________________ 
 
Social Security Number ______________________ First Life Income Beneficiary Signature _______________________________________ 
 
Drivers License Number___________________ Expiration_________ Issued By ___________________ Date Issued __________________ 
Please attach a copy of birth certificate, passport or drivers license for each income beneficiary. 

                                                                            ********** 
 
Second Life Income Beneficiary (in a two‐life agreement, the person named below, if still living, will receive the income after the death of the first life 
income beneficiary named above): 
 
Name (Title, First, Middle, Last) ________________________________________________________ Date of Birth ____________________ 
 
Address _________________________________________________ City/State Zip___________________________________________ 
 
Daytime Telephone # _____________________  Email Address __________________________________________________________ 
 
Social Security Number ______________________ First Life Income Beneficiary Signature _______________________________________ 
 
Drivers License Number___________________ Expiration_________ Issued By ___________________ Date Issued __________________ 
Please attach a copy of birth certificate, passport or drivers license for each income beneficiary. 
 
                                                                            ********** 
Donor Information (if different from Income Beneficiary): 

Name (Title, First, Middle, Last) ________________________________________________________ Date of Birth ____________________ 
 
Address _________________________________________________ City/State Zip___________________________________________ 
 
Daytime Telephone # _____________________  Email Address __________________________________________________________ 
 
Social Security Number ______________________ First Life Income Beneficiary Signature _______________________________________ 
 
Drivers License Number___________________ Expiration_________ Issued By ___________________ Date Issued __________________ 
Please attach a copy of birth certificate, passport or drivers license for each income beneficiary. 
                                                                             1 
 
I/We understand that when this gift annuity ends, the ultimate gift portion will remain with the Children’s Home and deposited in their 
Permanent Endowment Fund.   
This Charitable Gift Annuity will be funded with $ _____________ through: 
           [  ] Cash (check attached) or 
            
           [   ] Marketable securities (Attach a list including name, estimated value, and cost basis) 
            
           [   ] Other assets (Please contact the Gift Planning Office to discuss and ensure your gift can be accepted by our charity.) 

 

Gift Annuity payments should be made           [   ] Annually        [   ] Semi‐annually           [   ] Quarterly 
   
Gift Annuity payments should be deferred until 20____   
 
Gift Annuity payments should be sent to:       [   ] Home address            [   ] Bank/Holding Institution 
 
Name of Bank/Holding Institution _______________________________________________________________________________________ 
Address of Institution __________________________________________ City/State/Zip ___________________________________________ 
 
Bank Routing Number ________________________________________ Account Number ______________________________________________ 
(Please attach a copy of a voided check.) 
                                                                          
                                                                   ********** 
 
Donor Preferences: 
 
_____ I/We instruct the Florida United Methodist Children’s Home to notify any and all of the remainder beneficiaries of the gift once all contractual 
agreements are signed and executed. 
 
_____ I/We instruct the Florida United Methodist Children’s Home to keep the identity of any or all of the remainder beneficiaries of the gift in 
confidence until such time as disbursements are to be made. 
 
_____ I/We agree to allow the Florida United Methodist Children’s Home to list (my/our) name(s) as donor(s) in its publications as a way of 
encouraging others to make gifts to the Home. 
 

Please return this completed form to the above address with a check payable to The Florida United Methodist Children’s
Home, Inc. A copy of this application will be provided to you along with your gift annuity agreement. Indicate on a separate
sheet of paper any special requests for recognition or other instructions. Thank you!

                                                                    **********

                                        Charitable Gift Annuity General Disclosure Statement

The following disclosure is provided to you in accordance with the Philanthropy Protection Act of 1995 (P.L. 104-62) and Section 627.481, Florida
Statutes. We would be pleased to provide additional information upon your request.

Gift annuity payments are a general obligation of The Florida United Methodist Children’s Home, Inc., and they are backed by the full assets of
the organization. Our funds are invested in stocks, bonds, and federal obligations. We also maintain a gift annuity reserve in accordance
with the laws of the State of Florida. This annuity is not insured by an insurance company, is subject only to limited regulation by the State
of Florida, and is not protected or otherwise guaranteed by any government agency.

Common investment funds managed by our organization are exempt from registration requirements of federal securities laws, pursuant to the
exemption for collective investment funds and similar funds maintained by charitable organizations under the Philanthropy Protection Act of 1995.
Investment decisions are made by professional money management firm(s) and executed by the Home’s broker, who is registered under federal
securities laws. The Children’s Home staff and Board of Trustees closely monitor investments.

The Florida United Methodist Children’s Home was established in 1908. Responsibility for governing the Home is vested in its Board of Trustees.
The Children’s Home is a 501 (c) (3) not-for-profit organization registered in the State of Florida.




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