DONOR INFORMATION:

    LEGACY GIFT INFORMATION (Optional)

    I/We have included The Luzerne Foundation in our estate plans through the following (check all that apply):

    ESTIMATED VALUE OF GIFT

    PURPOSE OF GIFT

    RECOGNITION PREFERENCE

    ADDITIONAL INFORMATION

    Executor, Estate Attorney, and/or Financial Advisor Contact (optional):

    Additional Person (if applicable)

    COMMENTS OR SPECIAL INSTRUCTIONS

    DIGITAL SIGNATURE