UTFI Assessment Exclusion

UTFI Assessment Exclusion Form
Dean or Account Authorizer Approval
Dean / Account Authorizer

First NameLast Name
Account number from which the assessment will be withdrawn.
By checking this box and signing your name below, you are authorizing the assessment for this gift/donor/account to be withdrawn from the account above.
Dean or Account Authorizer Signature

Clear
Sender Name
Sender Email
example@example.com
The Assessment Exclusion Form should be submitted when a donor has requested an exclusion or when a donor organization has bylaws that prevent the payment of fees.

NOTE: Once an exclusion is finalized, the assessment will be withdrawn instead from a university S account. Prior to submitting this form, please identify that account by seeking authorization from its owner (typically a Dean). He or she will be required to sign this form after you submit it.

Automatic Exclusions:
- Gifts for capital projects (these will be identified by CFAE codes assigned to the allocations)
- Gifts to established endowments (funded at least $25,000 prior to 1/1/2020)
- Gifts to campus athletics (non-endowed)
- Gifts to UTC
- Gift annuities that already have a 25% fee in place
- Gifts to the UT Medical Center
Please contact Alumni and Donor Records (ADR@utfi.org) with any questions about assessment exclusions.
UTFI Staff Information
UTFI Staff Name*

First NameLast Name
UTFI Staff Phone Number

Area CodePhone Number
UTFI Staff Email*
example@example.com
Campus / Institute*

UTKUTMUTHSCUTIAMulti-Campus/Institute
Choose an Exclusion Level*

Allocation/AccountDonor - IndividualDonor - OrganizationGiftPledge
Reason for Exclusion Request and/or Additional Comments
Reason for Organization Exclusion

By requestBylaws preventing payment of fees
Allocation Code or Account Number to be Excluded
Ex: JOHNS_01 or S010021590
For Multi-Campus/Institute gifts:
1. Coordinate with your colleagues on all campuses associated with this assessment exclusion. You will need to identify all authorized account numbers from which the assessment will be withdrawn and enter them in the field below.
2. In the "Authorizer / Dean" fields, enter the name and email address of your Vice Chancellor of Advancement/Development, who will approve the assessment exclusion.
Enter the Account Number from which the Assessment will be Withdrawn*
Ex: Account # - S010021530
Account Number Authorizer / Dean Name

First NameLast Name
Account Number Authorizer / Dean Email
example@example.com
If gifts or grants are from foundations that have bylaws preventing payment of fees, then a copy of the bylaws must be uploaded.

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ANDI ID
For existing records (for individuals, exclusion will include spouse)
Donor Name
If an ANDI record needs to be created for the donor, fill out the fields below (name, address, email, phone number, and additional information).
New Donor Name

First NameLast Name
New Donor's Spouse Name

First NameLast Name
New Organization Name
New Donor Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
New Donor Email
example@example.com
New Donor Phone Number

Area CodePhone Number
Additional Information for New Donor
Ex: student ID
Dollar Amount of Gift/Pledge
Allocation
Payment Type
Ex: Check, Cash, Credit Card, Stock
Is the gift in your possession?

YesNo
If no, please explain where the gift is located and how UTFI will receive it.
Pledge Type

Gift AgreementPayroll DeductionOnlineRecurringACHStandard PledgePlanned GivingOther
If pledge type is "other," please explain.
Attach any additional or appropriate documentation (1).

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Attach any additional or appropriate documentation (2).

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Should be Empty:

UTFI Assessment Exclusion Form