Name of Plan Provider
Street Address/P.O. Box
City, State Zip
Re: Request for Direct Charitable Distribution from Individual Retirement Account
Dear Custodian, Trustee, or Plan Administrator:
Please accept this letter as my request to make a direct charitable distribution from my Individual Retirement Account # (Account Number) as provided by the Tax Increase Prevention Act of 2014.
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 2014 tax year. Therefore, it is imperative that this distribution be postmarked no later than December 31, 2014.
I further represent as follows:
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.
- I am over 70 ½ years of age. My date of birth is: ____.
- I will not receive any benefits from MPBN as a result of this rollover. This rollover is not directed to a charitable remainder trust, lead trust, gift annuity, pooled income fund or other non-qualified use, nor is it directed to a donor advised fund, supporting organization, family foundation, or purpose that is not qualified to receive a charitable IRA rollover.
- I understand that a charitable IRA rollover is currently available only for year 2014 and is limited to no more than $100,000 in total from my IRA or all of my IRAs combined.
- I will not incur any federal income tax liability as a result of this rollover therefore I elect out of withholding for this rollover. I will not accept any personal distribution of funds intended for this charitable IRA rollover.
- I understand that this charitable IRA rollover can count toward my required minimum distribution(s) for the year of the gift.
Donor’s name as listed on the IRA