Your name:

Date of birth:
(format xx/xx/xxxx)
Spouse's name:

Date of birth:
(format xx/xx/xxxx)
Address:

Telephone number:

Email address:

If the charitable trust is to be funded with cash, please state the amount:
$

If the charitable trust is to be funded with publicly traded securities, please state the estimated fair market value:
$
State the cost basis of these securities:
$
If you are not certain as to the exact cost basis, please estimate:
$

If the asset being considered is something other than cash or publicly traded securities, please state the nature of the asset

The estimated fair market value
$
The known or estimated cost basis
$
If the asset is real property, is there debt and how much
$

Your estimated rate of federal income tax (select one):
25% 28% 33% 35%

Select the percentage of income you would like to see illustrated in this example (select one):
5% 6% 7% 8% 9%

If you would you like us to send a copy of this illustration to your professional advisor, please provide the following:
Name

Email address

Telephone number

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

If you do not have an email account and want your illustration sent by mail, please check this box:
Send my illustration by regular mail