Check form

Please print this page. Complete the form and mail it, along with your check, to:

The Jefferson Trust
University of Virginia Fund
P.O. Box 400314
Charlottesville, VA 22904-4314

Please make the check out to U.Va. Fund and write the Jefferson Trust on the memo line of the check.

Thank you for your generosity!

Biographical Information

Your name:_________________________________________________

Home Address:______________________________________________

City:_______________________ State:__________ Zip:___________

Home Phone:_________________ Business Phone:________________

E-mail Address:______________________________________________

Accreditation

Should your spouse also receive credit for these gifts?

___ Yes ___ No

Matching Gifts

Many employees offer a matching gift program that can double or even triple your gift, and you will receive credit for your employer’s contribution. To find out if your company or your spouse’s company matches gifts, contact the company’s human resources department or check this online company search.

Does your company match gifts?

___ Yes ___ No

Company Name:_________________________________________

Authorization

This authorization will remain in full force and effect until the University of Virginia Fund has received written notification from me (or either of us) of its modification or termination in such time and in such manner as to afford the University of Virginia Fund a reasonable opportunity to act on it.

_____________________________________________
Signature

_____________________________________________
Signature, if Joint Account