AUTHORIZED FUND REPRESENTATIVE UPDATE FORM
The undersigned hereby requests the individual(s) listed below to be recognized as the authorized fund representative(s) for the Fund specified below. This Form supersedes all previously executed Authorized Fund Representative Forms for the Fund specified below. Authorized Fund Representatives have the exclusive privilege to recommend: 1) distributions/grants, 2) changes to the investment of fund assets, and 3) continuity and distribution upon dissolution. All fund correspondence will be sent to all Authorized Fund Representatives, unless otherwise specified. The Foundation recommends that the Authorized Fund Representative(s) review and provide the Foundation with updated contact information as needed.
Fund name:
*
Date of request:
*
-
Month
-
Day
Year
Date
New Authorized Fund Representative 1:
Name
*
First Name
Last Name
Address:
*
Street Address
Street Address Line 2
City
State
Zip Code
Phone:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
New Authorized Fund Representative 2: (optional)
Complete the following if you need to update a second contact person.
Name
First Name
Last Name
Address:
Street Address
Street Address Line 2
City
State
Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Current Authorized Fund Representative:
By signing this form, I certify that I am authorized to request changes to the authorized fund representatives for the fund listed above.
Name
*
First Name
Last Name
Signature
*
SUBMIT
SUBMIT
Should be Empty: