AUTHORIZED REPRESENTATIVE APPLICATION

AUTHORIZED REPRESENTATIVE APPLICATION

This form is to be completed by a recommended Authorized Representative to an existing donor advised

fund account established by an individual. The Donor/Primary Adviser or Joint Adviser for the Account

must also execute this application. Please type or print clearly using black or blue ink.

If you are establishing this Account and making the initial $10,000 contribution into the Account, you are

the Donor/Primary Adviser and must use the Donor/Primary Adviser Application.

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@.

When the form is complete, please review it, sign it, have the Donor/Primary Adviser or Joint Adviser sign it, and

send it via mail, overnight delivery, email or fax to:

BNY Mellon Charitable Gift Fund

201 Washington Street

Suite 024-0035

Boston, MA 02108

Email: bnymcharitable@

Fax to (866) 231-7663

Name of Donor/Primary Adviser on existing Account: ______________________________

Relationship to Donor/Primary Adviser: _________________________________________

Name of Account: ____________________________________________________________

Account Number: _____________________________________________________________

1. AUTHORIZED REPRESENTATIVE INFORMATION

Authorized Representative Information:

Mr.

Mrs.

Name: (First)

Ms.

(Middle)

Miss

Dr.

Other__________

(Last):

_________________________________________________________________

Social Security Number:

Date of Birth (mm/dd/yyyy):

_______________________

_______________________

BNY Mellon Charitable Gift Fund

Authorized Representative Application

Home/Legal Street Address (no P.O. Boxes):

_________________________________________________________________

City, State, Zip Code:

_________________________________________________________________

Country (if not United States):

_________________________________________________________________

Mailing Address (if different from above):

_________________________________________________________________

City, State, Zip Code:

_________________________________________________________________

Country (if not United States):

_________________________________________________________________

Home Telephone Number:

Business Telephone Number:

Email Address:

_______________________

_______________________

_______________________

Country of Citizenship ___________________________________________________

Country of Permanent Residency ___________________________________________

Occupation _____________________________________ (See below for examples)

Occupation Examples: Accounting/Auditing, Admin/Clerical, Attorney/Arbitrator/Paralegal, Banking Professional,

Car/Boat/Airplane Dealer, Casino/Gaming, Construction/Skilled Trades, Creative/Design/Architectural,

Defense/Military, Doctor/Medical/Health, Editorial/Writing/Publishing, Education, Engineering/Science/R & D,

Entertainment/ Sports/Arts, Homemaker, Hospitality/Food, Independent Investor, Information Technology, Insurance,

Manufacturing/Production Operations, Non-Bank Financial Professional ¨C (security broker/investment adviser/private

equity or hedge fund professional), Not for Profit Executive, Public Service/ Elected Official/ Embassy, Real Estate

/Leasing, Retail/Art Dealer/Antiques, Student, Transportation/Warehousing, Unemployed, Other (requires explanation)

Source of Wealth ________________________________ (See below for examples)

Source of Wealth Examples : Business Profits, Distribution from 401(k), Divorce, Inheritance/Gift, Insurance

Settlement, Law Suit, Salary, Sale of Business, Wealth Accumulation Over Time, Other (requires explanation)

Details of Source of Wealth (i. e. salary from management position at ABC business)

___________________________________________________________________

Source of Income _______________________________ (See below for examples)

Source of Income Examples: Employment Income, Household/Family Income, Inheritance, Investment Income,

Retirement Income, Social Security, Trust Income, Unemployment Income, Other (requires explanation)

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BNY Mellon Charitable Gift Fund

Authorized Representative Application

A Politically Exposed Person (¡°PEP¡±) includes persons, immediate family members, and close associates

who may have political exposure based on their occupation, relatives or associations. Please answer the

following questions related to PEPs:

Are you a Current or Former Senior Political Figure? __YES

Are you a Current or Former Head of State? __YES

__NO

__NO

Are you an Immediate Family Member or Close Associate of a Senior Political Figure? __YES

__NO

If YES, to any of the questions above:

Reason for Senior Political Figure Status _______________________________

Date of Position ___________________________________________________

Country of Position _________________________________________________

You may be requested to provide a copy of a current government issued photo ID such as a Driver¡¯s

License or Passport for identity verification purposes.

2. GRANT RECOMMENDATION PRIVILEGES

The Donor/Primary Adviser or Joint Adviser must choose one of the two types of grant recommendation

privileges this Authorized Representative may have:

Authorized Representative may make grant recommendations without approval from the

Donor/Primary Adviser or Joint Adviser

OR

Donor/Primary Adviser or Joint Adviser must approve all grant recommendations

3. AGREEMENT TO TERMS AND CONDITIONS

I hereby make this application to the BNY Mellon Charitable Gift Fund (¡°Gift Fund¡±) with the full

understanding of the following:

?

I understand that an Authorized Representative must be appointed by the Donor/Primary Adviser

or Joint Adviser. The Donor/Primary Adviser or Joint Adviser also has the privilege to remove

any Authorized Representative on the Account at their discretion. There can be no more than five

(5) Authorized Representatives for an Account at any given time.

?

I understand that as an Authorized Representative on the Account I may make grant

recommendations for the benefit of charitable recipients. The Gift Fund reserves the right to

review my grant recommendations and the right to reject any such recommendation. Restrictions

with respect to grant recipients and purposes are set forth in the Gift Fund¡¯s Policies and

Guidelines.

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BNY Mellon Charitable Gift Fund

Authorized Representative Application

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I understand that as an Authorized Representative I may make additions of $2,500 or more to the

Account. When making a contribution to the Account, I am irrevocably transferring ownership of

the assets to the Gift Fund and such assets will not be refunded to me in any manner. Once the

contribution has been accepted by the Gift Fund, the Gift Fund shall acquire all right, title and

interest in the contribution and the contribution shall be exclusively owned and controlled by the

Gift Fund. The underlying assets contributed and any future investment returns are exclusively

owned by the Gift Fund.

?

I understand that as an Authorized Representative to the Account I cannot make investment

allocation recommendations to the Gift Fund.

?

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.

I hereby certify that all information represented in Authorized Representative Application is accurate,

true, and complete. I will notify BNY Mellon Charitable Gift Fund in writing of any changes to the

information represented herein.

________________________________________________________________________________

Printed Name of Authorized Representative

_________________________________________________________________________________

Signature of Authorized Representative

Date

For Donor/Primary Adviser or Joint Adviser:

By signing this Authorized Representative Application I agree to the appointment of the applicant to the

Authorized Representative role for the aforementioned Account.

________________________________________________________________________________

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.

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