SAMPLE REQUEST TO IRA PLAN ADMINISTRATOR
[IRA Plan Administrator]
RE: Request for Charitable Distribution from Individual Retirement Account
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 Relief, Unemployment Insurance Reauthorization and Job Creation Act of 2010 and Sec. 408(d)(8) of the Internal Revenue Code of 1986, as amended.
Please issue a check in the amount of $______ payable to the organization at the address below:
The James Dick Foundation for the Performing Arts
PO Box 89
Round Top, TX 78954-0089
In your transmittal to the Foundation, please acknowledge my name and address as the donor of record in connection with this transfer. I also request to be copied on your transmittal.
If you have any questions or need to contact me, I can be reached at [telephone number]. Thank you for your assistance in this matter.
[Name of Plan Owner]