Sample letter of instruction from donor to IRA provider

{Date}
{Name of IRA Provider}
{Address}
{City, State, Zip}
(Call your plan provider to determine the most efficient way to send this letter of instruction)

Re: Request for Qualified Charitable Distribution from Individual Retirement Account

Dear Sir or Madam:
Please accept this letter as my request to make a qualified charitable contribution from my Individual Retirement under Sec. 1201 of the Pension Protection Act of 2006 (the PPA) and Sec. 408(d)(8) of the Internal Revenue Code of 1986, and made permanent under the Consolidated Appropriations Act of 2016. My account Number is {Account Number}.

Please issue a check in the amount of $____________ payable to {name of appropriate affiliated foundation} at the following address:

Anna Jaques Hospital
25 Highland Avenue
Newburyport, MA 01950

In your transmittal, please state my name and address as the donor of record in connection with this transfer, and copy me on your transmittal. It is my intention to have this transfer qualify during the {Year} tax year. Therefore, it is imperative that this distribution be postmarked no later than December 31, {Year}.

If you have any questions or concerns regarding this request, I can be reached at {Phone Number} or {Email Address}.

Thank you for your prompt attention to and assistance with this matter.

Sincerely,
{SIGNATURE OF IRA OWNER}