Planned Giving Form | Indiana Academy of Science

This form is to help you provide information about your planned gift to IAS. By sharing this information, you can help ensure that your gift will be used in accordance with your wishes. If this is a joint gift, please complete the spouse/partner fields and signature.

Name *

First

Last

Name (If joint gift)

First

Last

Date of Birth *

Date of Birth (If joint gift)

Address *

Phone *

Phone (If joint gift)

Email Address *

Email Address (If joint gift)

Gift Description

In consideration of my/our support of the goals of Prevail, Inc., I/we have made a gift provision in my/our estate plans as indicated below:

Checkboxes *

If you selected other charitable trust(s) or vehicle(s) please list below:

If you selected other (real estate, art, closely held stock, etc.) please list below: (copy)

Please provide a description of your planned gift to IAS, including an estimate of the value of the gift. All information will be kept confidential and does not bind you or your estate in any way.

Estimate $ (optional)

I/we would like my/our gift designated to:

First Choice
Second Choice
Third Choice

Recognition

Your planned gift entities you to become a member of the 1885 Society and have your name(s) listed with other society members. A plaque will added to our society recognition wall.

Select one of the following options:

Yes, I/we would like to be listed as a member of the 1885 Society.
Yes, I/We like to be a member of the 1885 Society, but list my/our gift as “Anonymous.”
No, please do not include me/us in the 1885 Society

If you selected yes, I/we would like to be listed as a member of the 1885 Society. Please provide the following name for recognition purposes:

This document does not bind you or your estate. By signing this form, you are simply acknowledging your current plans to benefit IAS in the future and giving us guidance as to your wishes. Upon submission, a copy of this form will be emailed to you for signature confirmation. Please confirm your signature in order to submit the completed form to IAS.

Questions? Liz Subrin, Executive Director Indiana Academy of Science director@indianaacademyofscience.org 317-507-9271