Donor Form

This Endowment Gift agreement is made by and between [NAME(S)] ("Donors") and the MUHAMMAD SUBUH FOUNDATION. Donors have delivered to MUHAMMAD SUBUH FOUNDATION [CHOICE #1 --a deed to real estate] [CHOICE #2–cash] [CHOICE #3–assets] as described in Schedule A at the end of this document.

WITNESSETH THAT:

Pursuant to this Agreement, Donors have transferred to MUHAMMAD SUBUH FOUNDATION the property described in Schedule A, receipt of which is hereby acknowledged by MUHAMMAD SUBUH FOUNDATION, subject, however, to all the terms and conditions set forth in this Agreement.
The property described in Schedule A is given to MUHAMMAD SUBUH FOUNDATION for addition to The Bapak Legacy Fund.
This endowment fund shall be operated in accordance with the Guidelines for Donors to the Bapak Legacy Fund. The undersigned Donor has received a copy of such guidelines and by signing this Agreement indicates that [CHOOSE ONE; he has/ she has/ they have] read and understood them.
This is the only Agreement with respect to this endowment gift by [NAME OF DONOR(S)].
This gift is irrevocable and is intended to qualify for charitable deductions under Internal Revenue Code section 170, 2522 or 2055, where applicable.
This Agreement shall be governed by the laws of the State of Virginia.

IN WITNESS WHEREOF, the Donor has signed and executed this Bapak Legacy Fund Endowment Gift Agreement and MUHAMMAD SUBUH FOUNDATION, acting through its duly authorized officer, has caused this Endowment Gift Agreement to be signed and accepted in the name of the MUHAMMAD SUBUH FOUNDATION.

DATED:__________________________

[NAME OF DONOR]______________________________________________

Mail To:

Muhammad Subuh Foundation
Leonard van Willenswaard, Trustee
P.O. Box 8571
3009 AN Rotterdam - The Netherlands
Tel. 010-2271865 Fax 010-2271440 / 2849307
email: umswikic@euronet.nl

MUHAMMAD SUBUH FOUNDATION

By:___________________________

Its:___________________________