Distribution Request Form
Donor Advised Fund
Donor Advised Fund Name.
*
Account Holder
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Signature
*
Date
*
-
Month
-
Day
Year
Date
I Accept
*
By selecting the “I Accept” button, you are signing this Agreement electronically. You agree your electronic signature is the legal manual/handwritten signature on this Agreement. By selecting “I Accept” using any device, means or action, you consent to the legally binding terms and conditions of this Agreement. You further agree that your signature on this document is as valid as if you signed the document in writing. You also agree that no certification authority or other third party verification is necessary to validate your signature, and that the lack of such certification or third party verification will not in any way affect the enforceability of your signature or any resulting agreement between you and the Jefferson Community Foundation.
I acknowledge that I will reveive no private benefit from this distribution
Please review the original application to make sure your request confomrs to the slated purpose of thies Distribution Request before completing this form.
Please type or print legibly, providing as much information as possible.
Distributions much be at least $100.
Grant distribtions must be sent by the Foundation office directly to the recipient.
The Board of Directors of the Jefferson Community Foundation, which usually meets the second Thursday of each month, must approve grant requests.
Grant requests must be submitted using a Distribution Request Form. Four to six weeks should be allowed for dsitribution.
Purpose of Distribution:
*
Recipient Name:
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Amount of distribution:
*
Comments
If this is for payment of a bill, please attach documentation.
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Jefferson Community Foundation, PO Box 81, Jefferson, WI 53549
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