Wentworth-Douglass Hospital
Health Foundation
Planned Gift Intention Information
Please use this form to share the details of your estate plan intentions for Wentworth-Douglass Hospital & Health Foundation. In recognition of your disclosure, we will be honored to invite you to join the 1906 Heritage Society, a select group of donors who have created a future gift intention to support the Hospital. This form is for informational purposes only. Your estate is not legally bound by submitting this form. This information will be held in the strictest confidence.
Name ______
Date of Birth:______
Address ______
City ______State ______Zip Code ______
Telephone Number ______E-mail Address ______
Gift Specifics
As evidence of our desire to provide a legacy of support for Wentworth-Douglass Hospital & Health Foundation I/we wish to inform the Foundation that you have been named in my/our estate plans. The type of gift is:
_____Charitable Gift Annuity _____Insurance Policy _____Bequest
_____Charitable Lead Trust _____Charitable Remainder Trust _____Retirement Plan _____Retained Life Estate
___ The gift is revocable. ___ The gift is irrevocable.
As of this date, the approximate value of my/our gift is $______(If your gift is a percentage of your estate, please indicate the approximate present value of that percentage.)
I/we designate this gift to be used for:
___Unrestricted Support (where the need is greatest as determined by the Wentworth-Douglass Hospital & Health Foundation Board of Directors)
OR
___The following department or program: ______
1906 Heritage Society
In recognition of your intention, it is our great pleasure to induct you as a member of Wentworth-Douglass Hospital & Health Foundation’s 1906 Heritage Society. This select group comprises those individuals that have included the Hospital in their estate plans.
__Yes, you may publicize my/our name(s) as members of the 1906 Heritage Society, which serves as motivation for others to consider planned gifts in support of the Hospital.
__I/We prefer my/our intentions to remain anonymous.
______
Donor(s) Signature(s) Date
Return completed form to:
Wentworth-Douglass Hospital & Health Foundation
789 Central Avenue
Dover, NH 03820