APPLICATION FOR GIFT ANNUITY

NAME:
NAME OF SPOUSE
STREET ADDRESS
CITY
STATE ZIP
HOME PHONE
WORK PHONE
EMAIL ADDRESS




SINGLE-LIFE GIFT ANNUITY* DATE OF BIRTH*
JOINT-LIFE GIFT ANNUITY* DATE OF BIRTH *
SOCIAL SECURITY NO:
SPOUSES'S SOCIAL SECURITY NO:

ESTIMATED FEDERAL INCOME TAX BRACKET 2001 (CHECK ONE)
 10% 15% 27.5% 30.5% 35.5% 39.5%

AMOUNT OF GIFT** $

Please check whether a single-life, or joint-life gift annuity and include date of birth for you and your spouse if jointlife

**By sending this request, you are asking us to prepare a proposal for a Gift annuity that will show you potential payout amount, tax deductions and tax savings based on the information you submit. Upon receipt of your request we will make arrangements to present the proposal to you at you convenience.