Name of Plan Provider
Street Address/P.O. Box
City, State Zip
Re: Request for Direct Charitable Distribution from Individual Retirement Account
Dear Sir or Madam:
Please accept this letter as my request to make a direct charitable distribution from my Individual Retirement Account # (Account Number) as provided by the American Taxpayer Relief Act of 2012.
Please issue a check in the amount of $____ payable to MPBN at the address below:
Maine Public Broadcasting Network
1450 Lisbon Street
Lewiston, Maine 04240
Tax ID: 22-3171529
In your transmittal to MPBN, please note my name and address as the donor of record in connection with this transfer, and copy me on your transmittal. It is my intention to have this transfer qualify during the 2013 tax year. Therefore, it is imperative that this distribution be postmarked no later than December 31, 2013.
If you have any questions or concerns regarding this request, I can be reached at (telephone or e-mail address). Thank you for your prompt attention to and assistance with this matter.