Thank you for including Death with Dignity in your estate plan, and for your part in ensuring all Americans
have the right to die with dignity. Please enter as much information as you are willing to share; we recognize
this gift is subject to change depending on personal and economic circumstance. Information on this form
is condential and does not create a binding obligation. By sharing your bequest intention with us, we can
thank you meaningfully for your future commitment and ensure we meet your wishes for your gift.
Bequest Intention Form
Name:
Address:
City:
State: ZIP:
PERSONAL INFORMATION
Spouse Name (if joint gift):
Phone Number: ( )
Email:
RECOGNITION
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GIFT INFORMATION
Death with Dignity National Center, a 501(c)(3) - provides education and defense
Death with Dignity Political Fund, a 501(c)(4) - supports political campaigns
I wish for my gift to support:
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Bequest in will
Gift in trust
Life insurance policy
Retirement plan or beneficiary designation
I have included Death with Dignity as a beneficiary of my:
Financial or investment accounts
Charitable remainder trust
Donor advised fund
Other asset (please describe)
(Optional) The current estimated value of my gift is $ or % of the asset indicated above.
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I prefer no public recognition.
For any public recognition, please list name(s) as follows:
Donors who provide a legacy gift will be enrolled in the Dignity Circle.
Name:
Address:
City:
ESTATE CONTACT INFORMATION (EXECUTOR, TRUSTEE, ADMINISTRATING COMPANY)
State: ZIP:
Phone Number: ( )
Email:
Signature:
Spouse Signature (if joint gift):
Date: / /
Date: / /
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