SAMPLE INSTRUCTION FORM FOR IRA CHARITABLE DISTRIBUTION
| Donor should also fax, mail or email a copy
of completed letter to: Danile Petrocelli, Director of Planned Giving dpetrocelli@clarku.edu Fax: 508 793 8872 |
Date: _________________________________
To:
________________________________
Plan Administrator
________________________________
Address
________________________________
City/State/Zip
RE: Request for Charitable Distribution from Individual Retirement
Account
Dear
Sir or Madam:
Please
accept this letter as my request to make a direct charitable distribution from
my Individual Retirement Account
# ___________________ as provided by the Sec.
1201 of the Pension Protection Act of 2006 and Sec. 408(d)(8) of the Internal
Revenue Code of 1986, as amended.
Please
issue a check in the amount of $________________ payable to Clark University at
the address below:
Attention: Daniel
Petrocelli
Clark University
950 Main Street
Worcester, MA
01610-1477
In
your transmittal to the charity, please indicate my name and address as the
donor of record in connection with this transfer, and please copy me on your
transmittal.
(Optional paragraph for requests occurring close to
year-end) It is my intention to have this
transfer qualify for exclusion during the (2006 or 2007) tax year. Therefore, it
is imperative this distribution be postmarked no later than December 31, 200__.
If
you have any questions or need to contact me, I can be reached
at__________________________.
Thank
you for your assistance in this matter.
Sincerely,
________________________________
Signature
________________________________
Name (Printed)
________________________________
Address
_______________________________
City/State/Zip
________________________________
Phone