Legacy form

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Legacy Society Intention Form

In Support of Ark-Valley Humane Society

Name(Required)

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

I/we have included the Ark-Valley Humane Society as a beneficiary of my/our:

If other, please specify:

Current estimated value of provision (optional)

Documentation attached (optional)

Max. file size: 64 MB.

All estate gifts are placed in the Ark-Valley Humane Society Board Restricted Reserve Fund, unless otherwise designated.(Required)

Ark-Valley Humane Society Board Restricted Operational Reserve Fund

Other (an AVHS staff member will reach out to you to further discuss your request designation)

Please include my/our name in Legacy Society listings as follows:

Please select all that apply(Required)

I would like my name to be anonymous in publications regarding the Legacy Society.

I give permission to publicly acknowledge my Legacy Society membership, including listing my name among other members in donor newsletters.

I give permission to publicly acknowledge my bequest upon my death.

Endorsement statement (optional): Why did you choose AVHS for your legacy donation?

This form is my statement of revocable bequest intention. Please sign below

Date

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