Name *

First Name

Last Name

Date of Birth

MM

DD

YYYY

Name

First Name

Last Name

Date of Birth

MM

DD

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Description of the gift:

Bequest in will or trust

Beneficiary of life insurance policy

Beneficiary of retirement plan

Charitable Gift Annuities

Charitable Remainder Trust

Real Estate

Other

Uncertain at this time; TBD

Publication and Communication

JAB Camp periodically publishes a list of Legacy Society Members, unless members request to stay anonymous. Publishing your intention encourages others, by means of your example, to make similar gifts. All details about type or amount of each member’s intention will remain confidential.

Please list my/our name(s)

Please do not publish my/our name(s)

This statement of intent does not constitute a legally binding pledge or agreement for me or for my estate. It documents my intent, and may be amended at any time.

First Name

Last Name

Date

MM

DD

YYYY