CONFIDENTIAL INTENTION FORM

 

 

 

Dear Donor,

We realize that many people who plan to support The Foundation of the Pennsylvania Medical Society through their estate and/or financial plans prefer to keep their intentions private. However, by letting us know of your plans, we can thank you during your life, and confirm that we are able to fulfill your stated intentions.

Please know that completing this form is non-binding — we understand that you may change your plans at any time. Please also know that all information you share with us is kept strictly confidential.

Lori Storm
Manager, Philanthropy & Hospital Relations
The Foundation of the Pennsylvania Medical Society
Phone: 717-558-7813
Email: lstorm@pamedsoc.org

 

Planned Gift Notification—Confidential

Personal Information

Name:_______________________________________________________________________________

Spouse Name:  ________________________________________________________________________

Address: _____________________________________________________________________________

City:_________________________________________________________________________________

Phone: ______________________________________________________________________________

Date(s) of Birth: _______________________________________________________________________

 
 
Your Gift Intention

Please provide the following information and attach a copy of the documentation or appropriate language from your will or trust, if available. Please complete all that apply.

  •  I/We want to support the mission of The Foundation of the Pennsylvania Medical Society through a planned gift as described below:
    •  I/We have included a bequest for The Foundation in my/our will or living trust.
    •  I/We have named The Foundation as a beneficiary of an asset:
      •  Retirement Plan
      •  Bank, Investment, or Other Financial Account
      •  Life Insurance Policy
      •  Other:__________________

The anticipated value of my/our gift is/will be approximately $_________or_______% of my/our estate. (If possible, please include a copy of the bequest language or other wording describing your planned gift.)

Please provide a general description of the gift provision (such as, asset to be donated if other than cash or securities, how gift is to be used, whether gift is to create an endowment, etc.):

_____________________________________________________________________________________

_____________________________________________________________________________________

  •  Yes, you may include me/us in listings of planned gift donors.

Please indicate how you would like your name(s) to appear in our Sustainers Circle listings. (Please note the amount of your intended gift will not be published):

_____________________________________________________________________________________

  •  No, please do not include me/us in listings.

Signature(s):                                                           Date:

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