Legacy Form Test Page

Name*

First Name Last Name Date of Birth

Spouse Name

First Name Last Name Date of Birth

Primary Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Email*

I/we have included Gift of Life Howie's House in my/our will:*

A specific bequest
A percentage bequest
Other

Please provide the specific bequest amount, the percentage bequest and estimated value, or other.*

Planned gifts can take many forms. Please use this section to let us know if you have made additional plans to support Gift of Life Howie’s House

Have you made additional plans to support Gift of Life Howie's House?*

Yes
No

A life insurance policy

Primary beneficiary
Secondary beneficiary

Death benefit value Current cash surrender value

A Qualified Retirement Plan (IRA, 401k, 403b)

Primary beneficiary
Secondary beneficiary

A Qualified Retirement Plan (IRA, 401k, 403b)

Foundation interest percentage Current market value of plan

Charitable Remainder Unitrust or Annuity Trust

Interest Percentage Current market value of trust

Testamentary Charitable Lead Trust

Interest Percentage Expected Payout

Estimated total amount of bequest designated to Gift of Life Howie’s House:

Other

Please Describe

If possible, please provide more details (approximate amounts, etc.) about your estate provision or other planned gift for Gift of Life Howie’s House:

Estimated total amount of bequest designated to Gift of Life Howie’s House:

Documentation:

Please select one.

I/we included a copy of the portion of the will or the trust agreement or Designation of Beneficiary Form (401k, 403b, IRAs, Insurance) that applies to Gift of Life Howie’s House in which the House is named.
At a later date, I/we will send the portion of the will or the trust agreement or Designation of Beneficiary Form (401k, 403b, IRAs, Insurance) that applies to Gift of Life Howie’s House in which the House is named.

Other information Gift of Life Howie's House should know about my gift:

Membership Authorization and Release:*

Pledgor or donor names(s) listed below will be included in the listing of the Legacy Society members. Members who have made commitments of $10,000 or more will have their name and giving level added to the special Legacy Society Wall in the House living room (specific gift amounts will be kept confidential).

Yes! I authorize Transplant House d/b/a Gift of Life Howie’s House and its designated affiliates to use, disclose and publish the name(s) as listed above in connection with the Legacy Society and Legacy Society Wall for the purposes of awareness, development and promoting the mission of Gift of Life Howie’s House and organ and tissue donation.
I/we prefer that my/our name not be published and remain as an anonymous member of the Legacy Society.

If yes, please publish my/our name as follows:

You should consult with your tax advisor to determine the degree to which your gift may result in tax advantages to you, your estate, and your beneficiaries.

Email

This field is for validation purposes and should be left unchanged.

Planned Giving Membership Application

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