Name(s) ______

Address ______

StreetCityStateZip

Telephone ______

WorkHome

Email:______

1.I/We give the sum of $______and/or the following described property

______(description of assets given) to North Central Massachusetts Community Foundation (the “Foundation”); with the request, subject to the Articles of Organization and By-Laws of the Foundation, as they currently exist or may hereafter be amended, that the funds or property thus transferred be used to establish an Advised Fund (funds $10,000 or greater only), to be known as the ______Fund (name of fund).

(optional)

2. The intention and desire of the Donor that, in accordance with the Declaration and the Articles of Incorporation and By-Laws of the Foundation, as amended from time to time, the Fund be used for the following specific charitable purpose (Please initial one of the following):

______General Endowment Fund ______Greater Athol Fund

______Greater Gardner Fund______Nashoba Valley Fund

______Twin Cities Regional Fund

3.The investment objective is Total Return – to be invested longer term. (Balanced/Growth)

(initial) ______

4. Distributions will be made from the Fund in accordance with the Foundation’s spending rule as stated in the Finance and Investment Committee Recommendations of the Foundation, which may be modified by the Board of Trustees from time to time.

Note that all distributions are subject to the variance power contained in Article II (1) of the Articles of Organization of the Foundation.

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  1. I/We hereby acknowledge that I/we have been offered copies of and have reviewed the following documents:
  2. The Foundation’s Investment Policy Statement(initial) ______
  3. The Foundation’s Articles of Organization (initial) ______
  4. The Foundation’s By-Laws. (initial) ______
  1. Administrative Fee charges will be assessed on an annual basis as per the Foundation Guidelines which are subject to reasonable modification by the Board of Trustees.
  1. Timeframe of the Fund: Permanent Endowment
  2. The gift or property described above will be transferred to the Foundation using the following method (Please initial one of the following):

______Check______Securities-Gift Account Transfer

______Securities-Certificates Transfer______Other ______

______Securities-Electronic Transfer ______

(Please contact the Community Foundation for instructions on securities transfers)

For the donor (s):For Community Foundation of

North Central Massachusetts:

______

Signature DateSignature Date

______

Signature DateTitle

DONOR RECOGNITION:

_____Please publish my name in your publication(s) as it appears at the top of Page 1.

_____Please do not publish my name in your publication(s).

_____Please do not publish my name in your publication(s), however, you may use my name to

invite others to join the Community Foundation of North Central Massachusetts.

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