Mobile Menu Why Give? Plan Your Legacy Giving Options What You Can Give Resources Confidential Intention Form Information submitted through this webform is not legally binding. Personal Information Name: First Name: Last Name: Spouse Name: Spouse First Name: Spouse Last Name: Address: Address: City/Town: State/Province: - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code: Phone: Email: Date of Birth: Your Gift Intention Please provide the following information and attach a copy of the documentation or appropriate language from your will or trust, if available. Please complete all that apply. File Upload One file only.32 MB limit.Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods. I/We want to support the mission of the Fund for Public Health NYC through a planned gift as described below: I/We have included a bequest for the Fund for Public Health NYC in my/our will or living trust. I/We have named the Fund for Public Health NYC as a beneficiary of an asset: Retirement Plan Bank, Investment, or Other Financial Account Life Insurance Policy Other: Enter other… Approximate anticipated value of gift: Please provide a general description of the gift provision (such as, asset to be donated if other than cash or securities, how gift is to be used, whether gift is to create an endowment, etc.): Signature: Sign above CAPTCHA What code is in the image? Enter the characters shown in the image. This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Information submitted through this webform is not legally binding. Personal Information Name: First Name: Last Name: Spouse Name: Spouse First Name: Spouse Last Name: Address: Address: City/Town: State/Province: - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code: Phone: Email: Date of Birth: Your Gift Intention Please provide the following information and attach a copy of the documentation or appropriate language from your will or trust, if available. Please complete all that apply. File Upload One file only.32 MB limit.Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods. I/We want to support the mission of the Fund for Public Health NYC through a planned gift as described below: I/We have included a bequest for the Fund for Public Health NYC in my/our will or living trust. I/We have named the Fund for Public Health NYC as a beneficiary of an asset: Retirement Plan Bank, Investment, or Other Financial Account Life Insurance Policy Other: Enter other… Approximate anticipated value of gift: Please provide a general description of the gift provision (such as, asset to be donated if other than cash or securities, how gift is to be used, whether gift is to create an endowment, etc.): Signature: Sign above CAPTCHA What code is in the image? Enter the characters shown in the image. This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
