IRA Rollover Gift

91��Ƶר��

I have requested a qualified charitable distribution from my Individual Retirement Account payable to 91��Ƶר�� College.

Amount

IRA Administrator

Please direct my gift to

Please specify where to direct the gift to.

First name

Birth name

Last name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Phone

Class year

Upon receipt of payment from my administrator, I understand that 91��Ƶר�� will send me a written acknowledgement that states the amount of this charitable distribution, that no goods or services were transferred to me by your organization in consideration for this gift and that this contribution to 91��Ƶר�� College is not a gift to a donor advised fund or to a supporting organization described in section 509(a)(1) of the Internal Revenue Code of 1986.

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