Revocable Gift Form - Theriogenology Foundation

Revocable Gift Form

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As evidence of my/our desire to provide future support to the Theriogenology Foundation I/we hereby inform the Theriogenology Foundation that I/we have made a provision for a gift to the Theriogenology Foundation in my/our estate plans. I/we understand that the commitment is revocable and can be modified by me/us at any time.

**Note:
Donor First Name *Name as it should appear on official roster		Donor Last Name *Name as it should appear on official roster
Date of Birth *
Additional Donor First NameName as it should appear on official roster		Additional Donor Last NameName as it should appear on official roster
Additional Donor - Date of Birth
Address Line 1 *
City *		State *
Country		Zip/Postal Code *
Phone Number *		Fax number
Email Address *
How do you intend to leave a legacy? *		If you selected other, please explain
Executor name *		Executor Address *
Executor notification *The executor identified above has been notified of my intent and appropriate documents have been or will be created to make this gift a reality.	Has been notified Will be notified
This gift will be payable at *		If you selected other, please describe
Gift ValueI/we wish to inform the Theriogenology Foundation for long-term planning purposes only, that as of this date, the value of my/our gift is: $______________.**
**We hope that you will share the approximate amount of your gift with us so that we will be able to acknowledge your generosity appropriately.
Use of gift moniesIt is my/our desire that this gift be used to benefit the following, or where the need is greatest:
Donor recognition *Listing your name(s) among the 1954 Society members serves as a motivation for others to leave a planned gift to benefit the Theriogenology Foundation (the amount of your gift is NOT published).
Donor signature *Typing your name here serves as your signature		Donor 2 signatureTyping your name here serves as your signature
Date *

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