The American Foundation: Family Foundation: ILLUSTRATION REQUEST FORM

ILLUSTRATION REQUEST FORM

The information requested in this form will be used to help determine the proper charitable estate planning tools to achieve the donor’s objectives. After this confidential questionnaire is completed and returned to the American Foundation, the development staff will prepare and send planning suggestions and simple illustrations to the professional advisor and/or donor.

Name of Financial Advisor	Mailing Address
Title	Mailing Address
Company Name	Fax Number
Business Phone ( )	E-mail Address

Donor Name	Mailing Address
Name to be used for all correspondence
Date of Birth Age
Home Phone E-mail Address ( ) /	Business Phone E-mail Address ( ) /
Spouse Name (optional)	Date of Birth Age

Approximate Net Worth Approximate Income (AGI)

_____________________________________________________________________________________________

Family members involved in and/or receiving benefit from your estate plan. (Name, Age and/or Date of Birth)

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Describe the assets that compose your estate.

Asset Type Current Value Cost Basis Debt % Yield/% Growth

____________ ____________ ____________ ____________ ____________

* Include additional assets on a separate sheet if necessary.

Please rank donor’s financial and estate planning objectives (1 - 9).

Increase Current Income	_____	Diversify Assets	_____	Increase Charitable Gifts	_____
Increase Future Income	_____	Increase Benefits to Heirs	_____	Create Family Legacy	_____
Avoid Capital Gains Tax	_____	Reduce/Avoid Estate Taxes	_____	Asset Protection	_____

Please list additional objectives in the space provided:

_____________________________________________________________________________________________

Has any initial information been provided to the donor, written or verbal, on the following: (CIRCLE)

*Charitable Remainder Trusts *Gift Annuities *Gifts of Life Insurance

*Charitable Lead Trusts *Pooled Income Funds *Private Foundations

*Support Organizations *Component Donor Advised Foundation

In the future, what do you anticipate the return will be if you were to reinvest these funds?

Projected long term annual return of charitable trust or foundation ______%

Proposed Wealth Replacement to Heirs - Insurance Information (if applicable—typically set to equal the amount gifted)

__ Last to Die/Survivorship __ Individual (specify insured)

Death Benefit $ _______________ Annual Premium $ ___________________ Number of Premiums _____

Additional Details:

_____________________________________________________________________________________________

Please mail to
The American Foundation
4518 North 32nd Street, Phoenix, AZ 85018
Telephone: (602) 955-4770 Professionals call: (602) 522-8812 Fax: (602) 955-4707
Web site: americanfoundation.org E-mail: info@americanfoundation.org

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