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 to count this gift in the Imagine New Heights campaign 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 Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire, Sint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Bulgaria Burkina Faso Burundi Côte d'Ivoire Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Curacao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Barthelemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten (Dutch part) Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe 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 * Clear Spouse/Partner Signature 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
