Bequest Intent Form University of Utah Bequest Intent Form This document is a record of your intention to leave a gift to the University of Utah through your estate plan. This document does not bind you or your estate, and your gift will be treated as confidential. However, it does allow us to plan responsibly for the future and encourage other alumni and friends to consider the University of Utah in their estate plans. We recognize that gifts may change over time, and we hope that you will notify us of any changes. Thank you for your generosity to the University of Utah. Name * Name First First Last Last Email * Spouse/Partner Name Spouse/Partner Name First First Last Last Address * Address Address Address City City State/Province State/Province Zip/Postal Zip/Postal Country AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCôte d'IvoireCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthelemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country A gift has been provided for the benefit of the University of Utah through the following: * Will Retirement Plan Assets Real Estate Living Trust Life Insurance Policy Charitable Remainder Trust OtherOther The current estimated face value of the gift described above: * The gift described above is designated to benefit the following College, Program, Purpose and/or Fund: Dr. John R. Park Legacy Society Through the Dr. John R. Park Legacy Society, the University of Utah extends its warm appreciation to individuals who make known their thoughtful gift intentions through a legacy gift. The Park Legacy Society is administered through the Development Office. All donors who notify the University of Utah of a legacy gift are automatically enrolled in the Park Legacy Society unless they prefer to opt-out. If you have questions regarding the Park Society or this form, please contact any member of the Legacy Giving team at 801-581-6824. Please check as appropriate: * I/we wish to be acknowledged in university publications, recognizing that it may inspire others to give. I/we prefer to remain anonymous for publicity purposes. I hereby authorize the University of Utah and its officers, agents, employees, successors, licensees, and assigns to take photos and recordings of me and to and use my image, likeness, and appearance without compensation to me, for any educational, nonprofit, institutional, scientific, or informational purpose. This consent is completely voluntary. Signature * signature keyboard Clear Spouse/Partner Signature signature keyboard Clear *Please note that unrestricted gifts are used to support the greatest needs of the University of Utah as determined by the President. If you are human, leave this field blank. Submit Start Over Δ
