Planned Giving Statement of Intent This document is intended to assist the Granite State Independent Living Development Department in carrying out your wishes. This is a statement of intent and is not a legally binding commitment. NameThis field is for validation purposes and should be left unchanged. Donor Information Required fields are indicated with a *. Donor Name*(Required)Date of Birth(Required) MM slash DD slash YYYY Donor Name 2(Required)Date of Birth(Required) MM slash DD slash YYYY Address(Required) Street Address City State State / Province*AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Phone(Required)Email(Required) Names and DOB of children, if applicableType of Provision I/we are pleased to inform Granite State Independent Living that my/our current estate planning tool(s) identifies Granite State Independent Living as a beneficiary of my/our estate. We intend to support the Granite State Independent Living mission using the following deferred gift options: We intend to support the Granite State Independent Living mission using the following deferred gift options: Will Bequest Trust Charitable Remainder Trust Life Insurance Policy Charitable Gift Annuity IRA or Retirement Plan Beneficiary Designation Other Please specify other provisionThe estimated current dollar value of my gift is $ Enter Dollar AmountHow is this sum expressed? This sum is expressed as a specific dollar amount This sum is expressed as a percentage of my estate. Specify percentage of estate (1-100)Please enter a number from 1 to 100.Document Submission Enclosed, please find a copy of the document or selection that describes my future gift provision. Confidential Document Upload Drop files here or Select files Accepted file types: pdf, docx, doc, Max. file size: 10 MB. Purpose How should your gift be used? How should your gift be used? For unrestricted use For a specific project or programs For a specific named fund Unrestricted Specific Dollar Amount Percentage of Estate Unrestricted Dollar AmountUnrestricted PercentagePlease enter a number from 1 to 100.Specific project nameValue Type (Project) Specific Dollar Amount Percentage of Estate Project Dollar AmountProject PercentagePlease enter a number from 1 to 100.Specific named fundValue Type (Fund) Specific Dollar Amount Percentage of Estate Fund Dollar AmountFund PercentagePlease enter a number from 1 to 100. In recognition of the gift, I/we would like my/our names listed as: Name Financial Advisor Attorney/Advisor Name*(Required)Phone (US)*(Required)Email*(Required) Firm's Name*(Required)Address*(Required) Street Address City State State / Province*AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Recognition Recognition I/we permit Granite State Independent Living to acknowledge my/our commitment, although the terms of this gift shall remain confidential to the extent permitted by law. I/we prefer this gift to remain anonymous. Signature(Required)SignatureElectronic Signature Electronic Signature - l agree that typing my name here constitutes my legal signature
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