Information submitted through this webform is not legally binding. Personal Information Name: First Name: Last Name: Spouse Name: Spouse First Name: Spouse Last Name: Address: Address: City/Town: State/Province: - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code: Phone: Email: Date 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 NEOMED Foundation through a planned gift as described below: I/We have included a bequest for NEOMED Foundation in my/our will or living trust. I/We have named NEOMED Foundation as a beneficiary of an asset: Retirement Plan Bank, Investment, or Other Financial Account Life Insurance Policy Other: Enter other… I/We have named NEOMED Foundation as a revocable beneficiary of a charitable remainder trust. I/We have named NEOMED Foundation as an irrevocable beneficiary of a charitable remainder trust. Approximate anticipated value of 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 The Stanley and Lorraine Olson Heritage Society listings. (Please note the amount of your intended gift will not be published): No, please do not include me/us in listings. CAPTCHA What code is in the image? Enter the characters shown in the image. This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. Leave this field blank
