Qualified Charitable Distribution to CFSI

The form below is provided to expedite the process of establishing a designated pass-through fund using a Qualified Charitable Distribution (or IRA Rollover) gift.

The completed form you submit will be used to complete your fund agreement. Once the form is submitted, the Community Foundation will send a draft fund agreement to your email for review and signature. No gift should be made until the final, signed fund agreement is received by the Foundation. At that time you can instruct your IRA administrator to process your Qualified Charitable Distribution and to deliver it directly to the Community Foundation of Southern Indiana (tax ID 35-1827813) at 4108 Charlestown Road, New Albany, IN 47150.

If at any time you have questions, please call Linda Speed at 812-948-4662. You can also view this informational flyer with FAQs and more.

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Qualified Charitable Distribution Fund Form

*Please Note: This agreement must be completed and fully executed by all parties BEFORE you initiate the QCD gift from your IRA. All distributions must be made to IRS approved public charities. Support shall be divided among the charitable organizations listed in the amounts designated below and shall be for each organization’s general use unless designated otherwise. The minimum required to establish this Fund is $15,000.00. The minimum amount for each distribution from the Fund is $1,000.00 unless the Foundation approves a lesser amount in advance, as shown below. The distributable amounts listed below shall be distributed by the Foundation, as closely as possible, in accordance with the time frames and to the charitable organizations detailed. If, before the distribution is made, any of these organizations ceases to exist as an I.R.S. approved public charity, the Foundation will pro rate that Designated Charitable Organization’s portion among the others listed.

What is Your Name?*

Prefix First Middle Last Suffix

Address*

Street Address Address Line 2 City State ZIP Code

Daytime Phone*

Cell Phone*

Email*

CHARITABLE DISTRIBUTIONS

What Do You Want to Call Your Fund?*

Please include a preferred fund name. Example: John Smith 2022 Charitable Fund.

Name of Donor(s)*

Please insert the name of the person(s) who will be signing the fund agreement.

How Would You Like Mail Addressed to You?*

(Example: Mr. & Mrs. John Smith)

EXHIBIT A: Details of Your IRA*

Please provide the following information on your IRA Fund.

Company Name

Acct. #

Contact Info

Amount of Gift (Min. $15,000)

EXHIBIT B: Which Organizations Will Receive Grants From Your Fund?*

Please include the full list of charities you’d like to support including their name, address, the amount you would like to grant and when you want the grant sent (e.g. 01/01/2023). All grants will be made for “General Support” unless otherwise noted. To add additional charities, please click the ‘+’ on the far right-hand side. PLEASE NOTE: No grants will be awarded until IRS verification is completed by CFSI staff.

Charity Name

Charity Address

Amount

Date to Send Grant

Purpose

Administrative Fee*

There will be a one-time 2% administrative fee paid to the Foundation to establish your designated pass-through fund and make all grants in the manner you’ve listed. This amount will be included in your final fund agreement and can be paid separately or added to your initial contribution.

I will pay the 2% administrative fee separately.

I will add the 2% administrative fee to my list of distributions. This amount will be included in my gift amount to the Foundation.

Fund Information*

Once your form is submitted, CFSI will send a completed draft to your email for review and signature. Your fund is not final and no gift should be made until CFSI receives the final signed agreement. If you have any questions please call our office at 812-948-4662.

I accept

Name

First Middle Last Suffix

Signature*

Countersigned by CFSI: Linda S. Speed, President & CEO

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Qualified Charitable Distribution to CFSI

Qualified Charitable Distribution Fund Form

CHARITABLE DISTRIBUTIONS

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