Type of Fund Account

We are...

Participating
Non-participating

Donor Information

Primary Donor Name

First

Last

Phone

Email

follows Donor Value

Address

Address Line 1

Address Line 2

City

State

Zip Code

Date of Birth

Donor 2 Name

First

Last

Phone

Email

Address

Address Line 1

Address Line 2

City

State

Zip Code

Date of Birth

I want to remain anonymous

Yes
No

If you would like to list additional individuals as donor advisors on the fund with full authority to make grant recommendations, please attach their names and full contact information.

Fund Information

Fund Name

Usually donors choose to name their fund in honor of themselves, their family, a relative or a friend, for example "The Jones Family.” Donations will be listed by the fund account name in publications unless anonymity has been requested.

Fund Beneficiary/Successor

The account holder(s) may designate a beneficiary/successor to succeed as Donor Advisor of the fund after their death, incapacity or other disqualification. Or the account holder(s) may elect specific charities to receive all or a percentage of the fund. If a successor(s) or a named charitable organization is not named, the Cortland Community Foundation will transfer the balance of the fund to their unrestricted general fund, the Community General Fund. If you would like to add more than four beneficiaries/successors to succeed you as Donor Advisor of the fund, please attach a list of their names and complete contact information along with any special instructions if applicable.

Successor One

First

Last

Phone

Email

Address

Address Line 1

Address Line 2

City

State

Zip Code

Date of Birth

Successor Two

First

Last

Phone

Email

Address

Address Line 1

Address Line 2

City

State

Zip Code

Date of Birth

Successor Three

First

Last

Phone

Email

Address

Address Line 1

Address Line 2

City

State

Zip Code

Date of Birth

Please select one of the options below

Successor(s) named above succeed the donor(s) with full grant making recommendations, jointly if more than one successor is named
Separate accounts will be created for each of the successor(s) named above, in equal amounts with a $10,000 minimum balance per account. If each such account would not meet the minimum balance requirement, the successor(s) would have the option of recommending distribution(s) of the entire amount or combining the accounts to create a single account with at least a $10,000 balance

Fund Charitable Organization(s) Successor

As opposed to naming a beneficiary/successor, I (we) wish to have the account balance disbursed to the following charitable organizations as instructed.

Organization 1

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Tax ID

Choose one of the following disbursement options:

% of fund account
Dollar amount

Organization 2

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Tax ID

Choose one of the following disbursement options:

% of fund account
Dollar amount

If you would like to include additional charitable organizations please attach any additional sheet(s) listing the organizations and their complete contact information including the dollar amount or percentage you wish to have disbursed to each organization.

NOTE: The charitable organizations and disbursements listed above must meet the Grant Making Guidelines of the Cortland Community Foundation.

Contribution Information

The minimum fund account balance is $10,000, which must be funded within 1 year. Grant recommendations cannot be made until the minimum $10,000 balance has been met. I (we) understand that all contributions are irrevocable charitable donations and are not refundable.

Estimated Value of Initial Contribution

$

Form of Contribution

(1) Check - Made payable to Cortland Community Foundation and returned with this application to Cortland Community Foundation PO Box 466 Cortland, NY 13045
(2) Securities - Instructions for Electronic and Paper Stock Transfers available upon request
(3) Donation from Another Charitable Organization, Please specify below
(4) Other (i.e. Life Insurance Policy, Bequest in a will) - Please specify below

If (3), name the charitable organization

If (4), please specify

I (we) would like our contributions invested as follows

In a separate account
In an account pooled with other Donor Advised Fund Accounts

By signing below, I (we) request that the Cortland Community Foundation open a Donor Advised Fund Account as indicated above. I (we) have read and understand the Donor Advised Fund Account Policy and agree to its terms and conditions. I (we) understand the following:

1) The law requires final grant making decisions be made by the Foundation's Board of Directors. It is the intention of the Board to fulfill all grant recommendations

2) Grants recommended from the fund are to be made to qualified U.S. 501(c) public charities and used exclusively for charitable purposes, not for the private benefit of the
donor advisor(s)

Primary Donor Signature

Clear Signature

Donor 2 Signature

Clear Signature

Special Instructions:

To assist the beneficiaries/successors in their grant recommendations, please provide insight into what programs or organizations that were important to you. This may be done by listing specific non-profit organizations or special interest groups, such as education, environmental, arts, animal protection, etc… This information will also assist the Foundation's Board of Directors in approving grant recommendations given by the beneficiaries/successors.

Donor Advised Application/Agreement

Donor Information

Fund Information

Fund Beneficiary/Successor

Fund Charitable Organization(s) Successor

Contribution Information