SUCCESSION & PERSONNEL CHANGE REQUEST FORM All changes being requested on this form can only be made by the Donor/Primary Adviser or Joint Adviser on the specific Account identified in Section 1 below. Please contact the Gift Fund for additional information by calling (888) 213-7605 during normal business hours (Monday-Friday, 8:30am-5:00pm ET) or sending an email to bnymcharitable@bnymellon.com. When your form is complete, please review it, sign it, and send it via mail, email, overnight delivery or fax to: 201 Washington Street Suite 024-0035 Boston, MA 02108 Email: bnymcharitable@bnymellon.com Fax to (866) 231-7663 Change Requested (Select All That Apply): (s) Remove Additional Donor(s) Change Succession Plan 1. DONOR ADVISED FUND ACCOUNT Donor Advised Fund Account Name: Donor Advised Fund Account Number:
2. REMOVE AUTHORIZED REPRESENTATIVE There can be a maximum of five (5) Authorized Representatives for an Account at any given time. In the event that a Donor/Primary Adviser or Joint Adviser wants to add an Authorized Representative to the Account, an Authorized Representative Application will have to be completed. The application can be obtained through the Gift Fund. Any removed Authorized Representative loses the privileges accorded them by the Gift Fund as outlined in the Gift Fund s Policies and Guidelines. The loss of privilege includes, but is not necessarily limited to, making grant recommendations and making additional contributions to the Account. - 2 -
3. REMOVE ADDITIONAL DONOR In the event that a Donor/Primary Adviser or Joint Adviser wants to authorize an Additional Donor to the Account, an Additional Donor Application will have to be completed. The application can be obtained through the Gift Fund. Remove Additional Donor Remove Additional Donor If additional space is needed with respect to the removal of Additional Donors, please attach a statement including the name of the Additional Donor that is to be removed. Any removed Additional Donor loses the privileges accorded them by the Gift Fund as outlined in the Gift Fund s Policies and Guidelines. The loss of privilege includes, but is not necessarily limited to, making additional contributions to the Account. 4. CHANGE OF SUCCESSION PLAN You have the option of selecting one of the following succession plans upon your death, incapacity, refusal to serve, or any other event that would disqualify you as serving as the Donor/Primary Adviser: Recommending a Successor (an individual that will succeed you as the Donor/Primary Adviser), Recommending a charitable beneficiary (ies) to receive the proceeds of any remaining assets in the Account, or Transferring the remaining Account balance to the general charitable Grant Fund. 1 All recommendations as to Successors or charitable beneficiaries are subject to the final review and approval of the Gift Fund, in its complete and absolute discretion, at the time the recommendation would otherwise take effect. If you fail to identify the desired plan of succession, then upon your death, incapacity, refusal to serve, or other disqualification as Donor/Primary Adviser, the Gift Fund will transfer the remaining Account balance to the general charitable Grant Fund. 1 The Grant Fund is the Gift Fund s unrestricted charitable fund, which is established to make charitable grants. Donors may not recommend grants from this fund. Donors may contribute any amount directly to the Grant Fund and may also recommend transfers of $500 or more to the Grant Fund from any Account. - 3 -
Please select the desired succession plan and provide the requested information: OPTION #1 Recommended Individual Successor 2 Named Successor for role of Donor/Primary Adviser Mr. Mrs. Ms. Miss Dr. Other Date of Birth (mm/dd/yyyy): Home/Legal Street Address (no P.O. Boxes): Mailing Address (if different from above): Home Telephone Number: Business Telephone Number: Email Address: Contingent Successor for role of Donor/Primary Adviser (In the event that the Named Successor refuses to serve, becomes incapacitated, dies, or otherwise is disqualified) Mr. Mrs. Ms. Miss Dr. Other Contingent Successor s 2 Additional information will be required from the recommended Successor at the time of succession. Only after receipt of the information will the Gift Fund make a determination of acceptance regarding the recommended Successor. - 4 -
Date of Birth (mm/dd/yyyy): Home/Legal Street Address (no P.O. Boxes): Mailing Address (if different from above): Home Telephone Number: Business Telephone Number: Email Address: Contingent Charitable Beneficiary (In the event that the Named Successor and Contingent Successor (if applicable) refuses to serve, becomes incapacitated, dies, or otherwise is disqualified; the recommended Contingent Charitable Beneficiary organization listed below may receive the remaining balance of the Account, pending Gift Fund approval) Organization s Name: Federal Tax ID Number: Telephone Number: Mailing Address: - 5 -
OPTION #2 Recommended Charitable Beneficiary (ies) Charitable Beneficiary #1 Organization s Name: Federal Tax ID Number: Telephone Number: Mailing Address: Recommended Percentage of remaining Assets the Charitable Beneficiary is to receive: % Charitable Beneficiary #2 Organization s Name: Federal Tax ID Number: Telephone Number: Mailing Address: Recommended Percentage of remaining Assets the Charitable Beneficiary is to receive: % If additional space is needed with respect to recommended charitable beneficiaries, please attach a statement including any additional recommended charitable beneficiaries, the beneficiaries required contact information, and the recommended percentage of assets the beneficiary is to receive. - 6 -
OPTION #3 Grant Fund Transfer the remaining Account balance to the general charitable Grant Fund upon my death, incapacity, refusal to serve, or other disqualification as Donor/Primary Adviser. 5. SIGNATURE I hereby certify that all information represented in this is accurate, true, and complete. I have read and understand the terms of the of the Gift Fund s Policies and Guidelines, as applicable and as currently in effect and as amended from time to time, and I agree to be bound by the terms and conditions of these Policies and Guidelines. I can obtain a current version of the Policies and Guidelines upon request. Printed Name of Donor/Primary Adviser or Joint Adviser Signature of Donor/Primary Adviser or Joint Adviser Date BNY MELLON CHARITABLE GIFT FUND is a service mark of The Bank of New York Mellon Corporation. 2013 BNY MELLON CHARITABLE GIFT FUND. All rights reserved. - 7 -