Siskin Hospital Revocable Form

What legacy will you leave for future generations? When you make a plan to leave an estate gift to Siskin Hospital for Physical Rehabilitation, your gift ensures compassionate care for years to come.

As a recognition of your intent, we would like to include you in the Siskin Hospital’s Legacy Circle. The Legacy Circle preserves the ideals of Mose and Garrison Siskin, who established Siskin Hospital for Physical Rehabilitation and worked to benefit its future.

We welcome gifts of any amount for The Siskin Legacy Circle. To join this inspiring membership, will you let us know about your intent by completing the revocable gift form below:

Name

First Name

Last Name

Phone

(###)

###

####

Email

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

TYPE OF GIFT

I (We) have already included Siskin Hospital for Physical Rehabilitation in my (our):

Will or Living Trust

Beneficiary Designation - Life Insurance

Beneficiary Designation - Bank or Brokerage Account

Beneficiary Designation - Retirement Plan

Other

If "Other", please specify

HONORARIUM/MEMORIAL

This gift is in

Honor of

Memory of

Tribute Name

DESIGNATION

I would like my estate gift to Siskin Hospital for Physical Rehabilitation to be designated for the following purpose:

Capital Expense

Charitable Scholarship Fund

RESTRICTIONS

Please note any gift restrictions that may apply.

Note: This is not a legal obligation binding me or my estate.

Siskin Hospital Revocable Form

Thank you!

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