Planned Giving Declaration of Intent

Thank you for letting us know that you plan to leave a gift in your estate for Maryhurst’s vital work with children and families. Your generosity will support our ongoing efforts to prevent child abuse, restore hope, and empower survivors. Please complete this form with as much detail as is comfortable for you.

*NOTE* This form does not constitute a binding obligation but only serves to help Maryhurst recognize donors who have chosen to include a gift to Maryhurst in their estate. All information about this gift will be kept strictly confidential unless otherwise directed.

Donor Name

First Name Last Name

Partner name (if joint gift)

First Name Last Name

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.

Email

example@example.com

I/We have provided a gift to Maryhurst as described in my/our:

Will or Trust Life Insurance policy Retirement Plan or Beneficiary Designation Other assets (please describe)

The current estimated value of my/our gift is amount.

I wish to direct my/our gift to the following:

Where Maryhurst's needs are greatest As directed in a gift agreement/letter

Donors who provide a planned gift to Maryhurst will be recognized in our Legacy of Hope Society. (Only names will be listed – not gift amounts.)

I/We prefer no public recognition Please list my/our name(s) as follows:

I/we agree to the following:

This declaration of intent does not create a binding obligation. Maryhurst will keep the details of this agreement confidential unless otherwise directed. Maryhurst may contact me in the future to verify if the information in the agreement is still correct. Should any of the information I have provided change, I will update this form as needed.

Name of Executor or Trustee

First Name Last Name

Address of Executor or Trustee

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Executor/Trustee Phone Number

Please enter a valid phone number.

Executor/Trustee Email

example@example.com

Name of Administrating Company

(for retirement account or life insurance policy)

Administering Company Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Administering Company Phone Number

Please enter a valid phone number.

Administering Company Email

example@example.com

Name of Optional Additional Contact (family member, attorney, etc.)

First Name Last Name

Relationship of additional contact

Please list if this contact is a family member, attorney, financial advisor, etc.

Address of Additional Contact

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Additional Contact Phone Number

Please enter a valid phone number.

Additional Contact Email

example@example.com

Click the "Submit Form" button below to email your information directly to David Short(david.short@maryhurst.org), Maryhurst's Director of Donor Relations. You may also contact David by phone at 502.271.4584.

Planned Giving Declaration of Intent

Estate Contact Information: