Planned Giving Form

Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

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Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

We are pleased to recognize you as a legacy donor to ACCESS, Inc. in our annual report and other publications. You will also be included as a lifetime member of the All ACCESS Giving Circle. Please indicate your recognition preference by checking one of the following:

I/we wish to be anonymous.

Please recognize my/our gift as follows (name):

ACCESS, Inc. is named as a beneficiary of [check all boxes that apply].

Sections of my will or trust

Life insurance policy

Retirement account / plan

Investment or financial account

Other Asset (please identify in the text box below)

Please indicate where you would like your planned gift designated:

Endowment Fund

Capital Fund

Operating Fund