Planned Giving Intent Form

Statement of Intent Form

Name(Required)

First Last

Email(Required)

Phone(Required)

Address(Required)

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

Next of Kin (spouse or other) or contact other than yourself.(Required)

First Last

Relationship(Required)

Email(Required)

Phone(Required)

Address(Required)

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

I have included the SAME Foundation as a beneficiary of my trust or estate plan through (check all that apply):(Required)

Will or Trust

Charitable Remainder or Lead Trust

Life Insurance Policy

Charitable Gift Annuity

Remainer or Retirement Fund or IRA

Other Item or Asset

List other item or asset below

I estimate the current value of the gift to be(Required)

For recognition purposes, please list my name as follows (Ex: Mr. & Mrs. John Smith III or Smith Family Trust)(Required)

Check Boxes(Required)

Other Option(Required)

If you have any questions, please don’t hesitate to contact Kathy Off, 703-549-3800.

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