Response/Request Form

Printable Response/Request Form

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This printable form has been provided without headings or navigation links to facilitate printing. You may fill it out on line and then print it. You may then mail or fax it to us at:

415-970-2383 FAX
Richard Lamport
Planned Giving Consultant
HopeRehabilitation Services
223 Clipper Street
San Francisco, CA 94114

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 Life Insurance Charitable Remainder Trusts Retained Life Estate
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 to make a charitable gift. There are other gift options that might be better suited for your individual financial circumstances which we will be glad to discuss with you. This is entirely confidential and the information you provide will be held in the strictest confidence. Your birthdate: If this annuity is to last for the lifetime of another person in addition to yourself, please enter that other person's birthdate: 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: