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 mail or fax it to us at:

(651) 254-2378 FAX
Regions Hospital
640 Jackson Street, Mail Stop 11202C
St. Paul, MN 55101-2595

Your Name:
Your Title:
E-Mail Address:

     (We must have this to respond to you by e-mail)
Phone Number:
Work Phone:  
Mailing Address:
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 Annuity
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.

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With the following information, we will provide you with a calculation of your benefits using a Charitable Remainder Trust 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 trust 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 trust you wish to establish:

If you wish to fund the trust 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.

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