Contact Information

First Household Member

First Name

Last Name

Email

Phone

Date of Birth

Second Household Member

First Name

Last Name

Email

Phone

Date of Birth

Third Household Member

First Name

Last Name

Email

Phone

Date of Birth

Fourth Household Member

First Name

Last Name

Email

Phone

Date of Birth

City

State

Zip

Recognition

Please let us know how you would like to be listed as part of GLAD's Legacy Society.

How would you like to be listed as part of GLAD's Legacy Society?

I/we prefer to remain anonymous

I/we would like to be listed as:

Gift Type

The approximate current value of this planned gift is:

Can be a dollar value, percentage, or text.

If you are comfortable doing so, please upload any supporting documentation here or email it to Jordan Caress-Wheelwright at jcwheelwright@glad.org.

Gift Purpose

How would you like your planned gift to be allocated?

This gift is to be unrestricted and may be used to support GLAD’s highest priorities.This gift is to be used for the following purpose(s):

Signature (please type your name)

Date