Charitable Gift Annuity Inquiry Form
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Please fill out this form and mail it in the postage-paid
envelope. The information you provide does not obligate you
in any way to contribute for a gift annuity. It will simply
allow United Way of America to prepare an annuity illustration
for you. The illustration will show the amount of annuity
payments you would receive and the tax benefits available
to you.
1. I am interested in an illustration for:
__ __One life ____ Two lives (payments made to you and another
person for the duration of your lives)
2. The illustration should be in the amount of:
____ $10,000 ____ $25,000 ____ $50,000 $________ Other
3. The property contributed for the annuity would be:
____ Cash ____ Bonds ____ Stocks
Please indicate approximate cost basis if property other
than cash is to be contributed.
Cost basis $______
4. Names and birth dates of annuitants (those who will receive
annuity payments):
First annuitant: Second annuitant:
_________________ __ _____ ____________________________
Name Name
________________________ ____________________________
Address Address
________________________ ____________________________
City, State, ZIP City, State, ZIP
__________ ___________ _____________ _____________
Birth Date Telephone Birth Date Telephone
FAX: 757.853.3900-Marie Torrans
Phone: 757.853.8500, ext: 106
United Way of South Hampton Roads Foundation
mtorrans@unitedwayshr.org
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