Gift Intention Form

By completing this form, you are informing EFMN of your intent to make a future gift. This form is voluntary and nonbinding and may be modified or revoked at any time.

DONOR INFORMATION

First Name

Last Name

Would you like to list your Spouse or Partner?

YesNo

Spouse or Partner First Name (if applicable)

Spouse or Partner Last Name (if applicable)

Street Address

City

State

ZIP Code

Phone

Email

GIFT INTENTION DETAILS

I/We have made provisions for a future gift to the Epilepsy Foundation of Minnesota through (select all that apply):

Bequest in my/our will or trustBeneficiary designation (retirement account, life insurance policy, donor-advised fund, etc.)Other

Please specify:

ESTIMATED GIFT VALUE (OPTIONAL)

For planning purposes, the estimated value of my/our gift as of today's date is:

PURPOSE OF GIFT (OPTIONAL)

I/We intend this gift to support:

Area of greatest needI'd like to talk to someone about options for designating my giftOther

Please specify:

RECOGNITION PREFERENCES

Please indicate how you would like your gift intention acknowledged:

I/We authorize EFMN to recognize me/us publicly.I/We prefer to remain anonymous

Name(s) for recognition:

ADDITIONAL INFORMATION (OPTIONAL)

Please share any special instructions or information regarding your gift:

Donor Declaration

I/we understand that, by stating an amount, my/our estate is not legally bound by this statement, and I may choose to add to, subtract from, or revoke this bequest at any time, at my/our sole discretion.

Name of Person Completing Form:

Today's Date: