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HOSPITALS & FACILITIES

FIRSTHEALTH A-Z

FOR PATIENTS & VISITORS

OUR FOUNDATIONS

Response / Request Form

There is no obligation on your part in requesting information or a personal analysis of your financial circumstances. Any information provided by you will be maintained in the strictest of confidences, and any response by us is for your informational purposes only.

If you would prefer to mail or fax this information to us, please use our printable form.

Your Name:
Your Title:
E-Mail Address:	(We must have this to respond to you by e-mail)
Phone Number:
Work Phone:
Mailing Address:
REQUEST FOR INFORMATION \| BEQUEST ACKNOWLEDGMENT \| PERSONALIZED CALCULATION REQUEST
Information Request	Please send me information regarding: Cash Gift Appreciated Securities Real Estate Bequests Gifts of Life Insurance Gifts of Retirement Assets Charitable Remainder Trusts Charitable Gift Annuities Retained Life Estate (definition)
Are you considering a gift currently?	Yes No Uncertain
Would you like to inform us of a bequest or other gift?	Yes, I have made a bequest or other planned gift and would be pleased to have my name included as a donor. Yes, I have made a bequest or other planned gift but I would prefer to remain anonymous.
Additional Comments or Requests
Add to Mailing List	Yes - please mail to above postal address. Yes - please e-mail me as above. No thank you.
Calculation Request.	TOP OF FORM With the following information, we will provide you with a calculation of your benefits using a Charitable Gift Annuity. There are other gift options that might be better suited for your individual financial circumstances that we will be glad to discuss with you. This is entirely confidential, and the information you provide will be held in the strictest confidence. Age: If this annuity is to last for the lifetime of another person in addition to yourself, please enter that other person's age: The dollar amount of the annuity you wish to establish: If you wish to fund the annuity with appreciated assets, such as stocks, please indicate the original cost or basis of the assets (please disregard if the funding is to be with cash): Our calculation will make assumptions as to the payout rate and the actual date of the gift. These assumptions are simply to give you a general idea of the income and tax benefits such a gift will provide you. There are other variables that may affect the actual benefits. This calculation is just a general idea of the benefits based on the current information and market conditions available at this time. If you wish, you may set up the annuity now but defer the income to a future date. If so, please indicate the age (both ages if for two persons) at which you would like to start receiving annuity payments. Your age at payment start: Second person's start age:

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Please note, individual financial circumstances will vary. The information on this site does not constitute legal or tax advice. Donor stories and photographs are for purposes of illustration only. As with all tax and estate planning, please consult your attorney or estate specialist. All material is copyrighted and is for viewing purposes only. Use of this site signifies your agreement with the terms of use. The content in this Planned Giving section has been developed for the Foundation of FirstHealth and is owned by Future Focus. Please report any problems to section webmaster.

(800) 213-3284