Fillable Form A: PARTICIPANT APPLICATION

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Form A: PARTICIPANT APPLICATION

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ELCA Foundation 8765 West Higgins Road Chicago, IL 60631
1.800.638.3522 or 773.380.2700
elcafoundation@elca.org
PARTICIPANT APPLICATION
(Attach IRS Form W-9)
We request to participate in ELCA Endowment Fund A. We understand that the Endowment Fund of the
Evangelical Lutheran Church in America, dba ELCA Foundation, and Trustee of the ELCA Endowment Fund Pooled
Trust, has complete and sole discretion in accepting or declining our application. Complete terms and conditions
of investment are in the “Confidential Disclosure Statement of the ELCA Endowment Fund A of the ELCA
Endowment Fund Pooled Trust” accompanying this application and are hereby incorporated by reference.
I. APPLICANT INFORMATION
Application Date: Participant/Applicant Name:
Account Name:
ELCA Affiliation: Is the applicant an affiliated ministry of the ELCA? Yes No
Check one: Congregation Synod Other:
Federal Tax ID #:
Federal Tax Status (choose one): ELCA Group Exemption
501(c)(3) Exemption (provide proof of exempt status)
Has the applicant ever been denied inclusion in the ELCA Group Exemption? Yes No
Applicant has other ELCA Endowment Fund A accounts: Yes No
Existing Account Name(s) and Number(s):
Applicant Mailing Address:
Street or P.O. Box:
City: State: Zip Code:
Telephone: Email:
Regional Gift Planner Assisting You:
NOTE: Download IRS Form W-9 at www.irs.gov/pub/irs-pdf/fw9.pdf and attach completed form to this
application
Form A
(Page 1 of 4)
Requires ink signature plus
IRS Form W-9 as attachment.
ELCA Foundation 8765 West Higgins Road Chicago, IL 60631
1.800.638.3522 or 773.380.2700
elcafoundation@elca.org
II. DEPOSIT & DISTRIBUTION SPECIFICATION
Initial Deposit: Amount $ (Minimum initial deposit of $25,000 required at time of account
opening.) Please indicate how your initial deposit will be made:
Wire Transfer (preferred method). Email your application and W-9 to elcafoundation@elca.org.
A representative from the Foundation will provide you with wire instructions when your account
number has been established.
Check. Email your application and W-9 to elcafoundation@elca.org. A representative from the
Foundation will provide you with a deposit form when your account number has been established.
De
posits made on or after December 1, 2020, will be added to your account in the Fund based on the unit value
as determined on the last business day of the month prior to the deposit. No deposit of cash or liquidated
proceeds will be made until the Foundation receives the funds and the properly completed Form A.
Distribution Election (choose one):
Reinvest all quarterly distributions (We understand if we elect option 1 and we later determine a
withdrawal is required, the withdrawal will be processed within ten (10) business days from the date of
receipt of a completed Withdrawal Form - Form E)
Issue quarterly distributions on or about Mar. 31, June 30, Sept. 30 and Dec. 31
Issue other distribution as approved by the ELCA Foundation (requires prior approval from Foundation)
A
dditions to Principal: Participants may make additions to principal at any time. All additions must be
accompanied by an Addition to Principal form (Form B). The addition to principal will be converted to units
according to the most recent Valuation Date.
Permission for Direct Additions to Principal: We understand that some individuals (i.e., donors to our
organization) may contact the Endowment Fund A administrator to make a gift directly to our account. As owner
of such account, we must approve such deposits. The Participant’s chief executive (i.e., president, senior pastor,
bishop) agrees to such deposits by initialing the following statements:
The ELCA Foundation, as administrator for Endowment Fund A, may deposit contributions which are
designated for the above-named account.
The Participant will inform donors that deposits made directly to the above-named account are made to
a fund owned by the Participant and not a fund owned by the ELCA.
Formal receipting of the gift for income tax purposes will be provided by the ELCA Foundation. Any
acknowledgement made by the Participant will not include information that could be considered a receipt.
Request for Online Account Access: Online access is limited to view-only access of statements.
We request online access. Send instructions for access to:
Name: Email:
Form A
(2 of 4)
Requires ink signature plus
IRS Form W-9 as attachment.
ELCA Foundation 8765 West Higgins Road Chicago, IL 60631
1.800.638.3522 or 773.380.2700
elcafoundation@elca.org
III. AUTHORIZATION AGREEMENT FOR DIRECT DEPOSIT
Our organization hereby authorizes the ELCA Foundation to initiate Automated Clearing House (ACH) credit entries
and/or correcting debit entries to our bank account for Endowment Fund Pooled Trust distributions and/or other
withdrawals. PLEASE ATTACH A VOIDED CHECK TO THIS APPLICATION.
Account Information:
Checking Account Savings Account Other:
Financial Institution Name:
City: State: Zip Code:
Bank’s transit routing number: Account number:
Congregation’s Federal Employee Identification Number (EIN):
IV. AUTHORIZING RESOLUTION & CERTIFICATION
The following individuals are authorized by the governing body of Participant to engage in all matters associated
with this account. Please note: If a change in the individuals authorized to act occurs, Participant must complete
Form C: Change in Authorization. The original must be received by the ELCA Foundation for it to take effect.
Authorized Participant Representative(s):
Number of signatures are required for withdrawals or changes in distribution (choose one):
1 2 3
By signing below, I/we acknowledge I/we received, read, and understand the most recently published Confidential
Disclosure Statement of Endowment Fund A and understand the risk factors in investing in Endowment Fund A.
I/we further understand that the Endowment Fund of the ELCA can remit funds only upon the request of
Authorized Participant Representative(s).
1. Name: Title:
Signature: Email:
2. Name: Title:
Signature: Email:
3. Name: Title:
Signature: Email:
Form A
(3 of 4)
Requires ink signature plus
IRS Form W-9 as attachment.
ELCA Foundation 8765 West Higgins Road Chicago, IL 60631
1.800.638.3522 or 773.380.2700
elcafoundation@elca.org
Notary Attestation
Attestation by Pastor or CEO:
I, (name), as (title) of
(organization) attest that the
individual(s) named above are the authorized representatives for this account.
Signature
Date:
STATE OF
COUNTY OF
On this day of , 20 , before me, the undersigned notary public, personally
appeared , personally known to me or proved to me on the basis of satisfactory
evidence to be the individual whose name is subscribed above and acknowledged to me that he/she/they
executed the same in his/her/their capacity, and that by his/her/their signature on the instrument, the individual,
or the person upon behalf of which the individual acted, executed the instrument.
Notary Public
My commission expires:
For ELCA Foundation Use Only:
Participant Number: _ Account Number: E _
Voided check received W-9 received
Form revised December 2020
Form A
(4 of 4)
Requires ink signature plus
IRS Form W-9 as attachment.
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Form A: PARTICIPANT APPLICATION

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Completed 21 October 2021

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