Charitable Bequest Intent Form

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*Name:
Date of Birth:
Address:
City:
State:
Zip:
Phone:
Email:
Bequest Specifics
As evidence of our desire to provide a legacy of support for Catholic Medical Center, I/we wish to inform Catholic Medical Center that you have been named in my/our estate plan. As of this date, the approximate value of my/our gift is $. (If your gift is a percentage of your estate, please indicate the present value of that percentage.)
I/we designate our gift to be used for:
	Unrestricted support (where the need is greatest as determined by Catholic Medical Center and its Board of Directors)
	OR
	The following department or program
Charles F. Whittemore Society
In recognition of your intention, it is our great pleasure to induct you as a member of the Catholic Medical Center Charles F. Whittemore Society. This select group is comprised of those having made a planned gift investment in Catholic Medical Center.
	Yes, you may publicize our names as members of the Catholic Medical Center Charles F. Whittemore Society, which can serve as motivation for others to consider making a planned gift in support of Catholic Medical Center.
	No, I prefer my/our intentions be kept anonymous.