Request Distribution from Traditional or Roth IRA
for charitable Purposes
Date: _________________________
IRA Plan Administrator’s Name & Address:
___________________________________________
___________________________________________
___________________________________________
___________________________________________
___________________________________________
___________________________________________
Dear IRA Plan Administrator:
Please accept this letter of instruction as authorization to make a tax-free distribution from my Individual Retirement Account for charitable purposes as described in Section 208 of the American Taxpayer Relief Act of 2012.
A distribution in the amount of $________________ shall be made to:
Prairie Public Broadcasting, Inc.
Attn: Ann Clark, Director of Development
207 N. 5th Street
Fargo, ND 58102
Tax ID: 45-0276899
Please include my name and address with the distribution for acknowledgment purposes and please copy me on your transmittal.
If there are any questions concerning this distribution, please contact me at _________________.
Sincerely yours,
________________________________________
Account #: _______________________________
cc: Ann Clark, Prairie Public Broadcasting, Inc.