* Date:

* Distribute to Organization:

* Amount:

Organization Street Address:

Organization City:

Organization State:

Organization Zip:

Special Instructions:

* Donor Email:

* First Name:

* Last Name:

* Phone Number:

Your Fund’s Name (if known):

I certify that the above recommendations do not represent the payment of a pledge or other obligation I or any Advisor to this Fund have made, nor do I or any advisor to this Fund expect any personal benefit from these charitable distributions. I also acknowledge that neither I nor any advisor to this Fund control the Board of the above charities either directly or indirectly.