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Please direct gift distributions and documents to us at:

Cincinnati Children's
Legacy Planning
3333 Burnet Ave, MLC 9002
Cincinnati, OH 45229-3026
1-513-803-0568

Confidential Legacy Intention Form

Welcome to the William Cooper Procter Legacy Society—our way of recognizing friends like you who share our vision to improve outcomes for the children and families who rely on us.

Your support saves lives.

Legacy gifts, such as those included in a will or trust, or as a beneficiary of life insurance or retirement assets, advance life-saving care and research discoveries for generations to come. Membership in the Wiliam Cooper Procter Society involves no dues or obligations. It simply helps us thank and recognize you for the plans you have made, as well as the financial future to carry out our mission. .

Click if you prefer to print this form and mail it to our office.

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Question - Required - Name:

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Question - Required - Email:

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Question - Required - Address:

(Maximum response 255 characters, approx. 5 rows of text)

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Question - Required - Phone Number:

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Question - Required - Preferred method of communication:
Please make between 1 and 2 selections from the choices below.

	Phone
	Email

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Question - Required - Date of Birth:

Month

Day

Year

Your gift may inspire others to give, and we hope you are willing to be acknowledged in Cincinnati Children’s publications with other members of the William Cooper Procter Legacy Society.

Question - Not Required - How would you like your name to appear when we recognize your gift?

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Question - Required - I wish to remain anonymous.

Yes

No

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How often would you like to hear from us?

(Select one of the available choices or enter a different answer.)
Question - Required -How often would you like to hear from us? Click this to indicate that you will select an existing value. Tab to next input." How often would you like to hear from us?
How often would you like to hear from us? Click this to indicate that you will enter a new value. Tab to next input." How often would you like to hear from us? Provide your answer here

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Question - Required - I/we have included my/our estate plan a gift to Cincinnati Children's for:

Cincinnati Children's Greatest Needs

A specific program or area at Cincinnati Children's

*Should you wish to designate your gift to a specific purpose, we strongly recommend that you contact us to discuss the restriction to make sure that we are able to honor your inentions.

Question - Not Required - If you selected a specific program or area, please list the name:

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Question - Required - Please describe your planned gift: (Please select all that apply.)

	Will
	Trust
	IRA or Retirement Plan Account beneficiary
	Life Insurance Policy beneficiary
	Donor Advised Fund beneficiary
	Charitable Remainder Trust
	Charitable Gift Annuity
	Charitable Lead Trust
	Real Estate
	Other

Question - Not Required - Name of Trust, IRA Administrator, Life Insurance Company, and/or DAF Sponsor/Foundation (if applicable)

(Maximum response 255 characters, approx. 5 rows of text)

Question - Not Required - Other planned gift:

(Maximum response 255 characters, approx. 5 rows of text)

Question - Not Required - As of today's date, I estimate the value of this gift to be approximately. (We understand the size of your future gift might be significantly different than your current estimate.)

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Question - Required - Are you willing to share your story for use in a future publication?

Yes

No

Cincinnati Children’s would like to recognize your attorney and/or other professional advisor(s) who have assisted you in creating your legacy gift. We hope you will take a moment to add name(s) and address(es) below so we can thank them personally at one of our special events held for professional advisors.

Question - Not Required - Advisor's Name

Question - Not Required - Advisor's Address

(Maximum response 255 characters, approx. 5 rows of text)

Question - Not Required - Advisor's Phone Number

Question - Not Required - Advisor's Email Address

Cincinnati Children’s wishes to assure you that your statement of intention does not constitute a legal obligation and will not be legally binding in any way for you, your heirs, or your estate. Further, Cincinnati Children’s understands that the size of your future gift may be different from the amount estimated above.

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Question - Required - Printed Name

Questions may be directed to:

Suzanne M. Rohlfs, JD, CAP®
Director, Legacy Planning
Telephone: 513-636-1192
Email: suzanne.rohlfs@cchmc.org

Kelli M. Kurtz, CAP®
Senior Officer, Legacy Planning
Telephone: 513-636-5685
Email: kelli.kurtz@cchmc.org

Learn more about legacy giving at cincinnatichildrens.org/legacyplanning

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3333 Burnet Avenue, Cincinnati, Ohio 45229-3026 | 1-513-636-4200 | 1-800-344-2462

Thank you for supporting Cincinnati Children’s!

Confidential Legacy Intention Form

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