Mouton Society Membership Form
Everyone who has included Maryville University in the stewardship of their interest and financial resources
with a planned gift automatically qualifies for membership in the Mouton Society.
I/We have remembered Maryville University with one or more of the following planned gifts:
Bequest commitment Life insurance policy Charitable gift annuity Retirement plan funds
Charitable remainder trust Other (please describe)
In the amount of (please indicate approximate amount) $
My/Our planned gift is to be used for:
Unrestricted purposes at Maryville University
Other (please describe)
This Declaration of Intent is an expression of my/our present plans. It is not legally binding on my/our estate.
Members of the Mouton Society may be listed or unlisted. All members receive invitations to
Mouton Society events.
I/We choose to be listed members. Please include my/our names, without disclosing the amount or
type of planned gift, in all Mouton Society honor rolls as follows: (please print your name(s) as to how you
would like to be listed)
I/We choose to be unlisted/anonymous members.
Date of Birth Date of Birth
Signature Signature
Date Date
10/15
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