Planned Giving Confirmation Form | La Jolla Symphony & Chorus

LA JOLLA SYMPHONY AND CHORUS ASSOCIATION expresses its sincere gratitude for your
willingness to support our future through an estate commitment. Please take a moment to complete this
confidential form and return it to us as a confirmation of your intentions:

I/We confirm the following planned gift to La Jolla Symphony and Chorus Association:

If you selected Other above, tell us which other beneficiary designation:

If you selected Bequest, please complete one statement:

Stated as: ____%

Specific Amt: $______

Residual:

Estimated $ Value of Gift:

Designation of gift:

If Restricted, restricted to:

THERESE HURST PLANNED GIVING SOCIETY

La Jolla Symphony and Chorus Association welcomes you as a member of the Therese Hurst
Planned Giving Society, which recognizes donors who have made a planned gift for our benefit.
Please indicate below how you would like your name to appear in our recognition materials or if
you wish to remain anonymous.

I/We grant you permission to publish my/our name(s) as follows:

I/We wish to remain an anonymous member(s).

First Name

Spouse's First Name (if applicable)

Date of Birth:

Last Name

Spouse's Last Name (if applicable)

Spouse's Date of Birth:

Address:

Phone Number:

City:

Phone Number 2:

State

Email:

Zip Code:

Signature

Date:

Spouse's Signature

Date:

La Jolla Symphony and Chorus Association is a 501(c)3 non-profit charitable corporation.

Federal Tax I.D. No. 95-1962652