CONFIDENTIAL

STATEMENT OF INTENTION for ESTATE-BASED GIFTS

Estate-based giving is critical to the continuing vitality and success of the Institute of Medicine. We deeply appreciate your intention to include the Institute in your long-term philanthropic plans and ask you to complete this document for two reasons: first, so that we may appropriately recognize your philanthropy; second, to create a record that will ensure that your contributions are used in the manner that you desire. This form is not a legally enforceable commitment.

Name:

Address:

Phone:

TYPE OF PROVISION

I have made provisions for the Institute of Medicine in my estate plans for one or more of the following:

Estimated Present Value

 % of residue of estate $

 Outright bequest in my will $

 Contingent bequest if spouse or other heir predeceases me $

 Bequest in my spouse’s will if I predecease my spouse $

 Life insurance policy with IOM as beneficiary $

 Trust arrangement with the IOM as a beneficiary; $

 The NAS is a beneficiary of my retirement plan $

 Donor advised fund residuum $

PURPOSE

(Please indicate the designated use of gift.)

$ or % for the Institute of Medicine to expend as determined by the Council.

$ or % for the specific purposes of:

By initializing on the foregoing line, I give permission to the Institute of Medicine to publicly recognize my gift intention.

Date Signature

The Heritage Society recognizes members and friends who have contributed to the future of the National Academies through documented bequests, gift annuities, trusts, and other gifts.

If you have questions about your gift plans or the information requested on this form, please contact Ellen Urbanski, Director of Development for the IOM, (202)334.2371 or eurbanski@nas.edu .