IRA Qualified Charitable Distribution
Date: ________________________________
Nebraska Farm Bureau Foundation
Attn: Megahn Schafer
PO Box 80299
Lincoln, NE 68501
Dear Megahn:
I have requested a qualified charitable distribution from my Individual Retirement Account
payable to the Nebraska Farm Bureau Foundation as described below:
IRA Plan Trustee/Administrator Name: __________________________________________________________
Account Number: _________________________________ Distribution Amount: $_______________________
Gift Use:
General Support/Greatest Needs
Special Instructions: _________________________________________________________________________
It is my intention that this gift be treated as a qualified charitable distribution for the tax
year. Accordingly, when payment is received from my trustee/administrator, please send
me a receipt and written acknowledgement indicating the amount of my gift, that no goods
or services were transferred to me by the Nebraska Farm Bureau Foundation in
consideration for this gift, and that my gift will not be placed in a donor advised fund or
supporting organization.
If you have questions, please contact me at: _________________________. Thank you for your
attention to this request.
_______________________________________ ________________________________________________________________
Signature Date
_______________________________________ ________________________________________________________________
Printed Name Mailing Address
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