Planned Gift Form Personal Information Name First name Middle name Last name Preferred Email Preferred Email Confirm email Spouse/partner Information (optional) Spouse Name: First name Last name Select the gift type(s) Will Living trust Charitable remainder trust Retirement account/IRA Life insurance policy Other asset (describe below) Enter other… Enter the estimated value(s) of your gift(s) to Dartmouth When will Dartmouth Health and/or the Geisel School of Medicine receive this gift? Dartmouth receives this gift after My life The life of my surviving spouse/partner Other Enter other… How will this gift be used? Highest Priorities: Geisel School of Medicine Dartmouth Health Restricted use: Geisel School of Medicine Dartmouth Health Describe restricted use Attach document Please attach the relevant section of your will, trust, or beneficiary designation form. One file only.32 MB limit.Allowed types: jpg, png, pdf, doc, docx, gz, tar, zip. Recognition We periodically publish the names of those who make bequests to inspire others. May we include yours? Yes, publish my name and gift amount range to inspire others. No, please don't publish my name. Address Address Address 2 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 THIS IS NOT A LEGALLY BINDING DOCUMENT. Dartmouth Health and the Geisel School of Medicine recognizes that your plans may change over time; please consider notifying us of future changes.Questions? Emails or call (603) 646-5858 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. Need Help? If you don’t find the information you’re looking for here, please contact Cate Meno, Director of Annual Giving, at 603-646-5794 or Cate.Meno@Hitchcock.org Ways to make a gift
Personal Information Name First name Middle name Last name Preferred Email Preferred Email Confirm email Spouse/partner Information (optional) Spouse Name: First name Last name Select the gift type(s) Will Living trust Charitable remainder trust Retirement account/IRA Life insurance policy Other asset (describe below) Enter other… Enter the estimated value(s) of your gift(s) to Dartmouth When will Dartmouth Health and/or the Geisel School of Medicine receive this gift? Dartmouth receives this gift after My life The life of my surviving spouse/partner Other Enter other… How will this gift be used? Highest Priorities: Geisel School of Medicine Dartmouth Health Restricted use: Geisel School of Medicine Dartmouth Health Describe restricted use Attach document Please attach the relevant section of your will, trust, or beneficiary designation form. One file only.32 MB limit.Allowed types: jpg, png, pdf, doc, docx, gz, tar, zip. Recognition We periodically publish the names of those who make bequests to inspire others. May we include yours? Yes, publish my name and gift amount range to inspire others. No, please don't publish my name. Address Address Address 2 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 THIS IS NOT A LEGALLY BINDING DOCUMENT. Dartmouth Health and the Geisel School of Medicine recognizes that your plans may change over time; please consider notifying us of future changes.Questions? Emails or call (603) 646-5858 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.