Gift Intention Form

Children’s Hospital Los Angeles: Gift Intention Form

Name (Required)

Additional Name (Optional)

Email (Required)

Phone Number (Optional)

I/we have made a provision to leave a legacy to Children’s Hospital Los Angeles through my/our:

Will

Trust

Life Insurance

Retirement Plan Assets

Charitable Gift Annuity

Other

If you selected "Other" or would like to share the value of your gift, please contact Steven Adamian, JD, at (323) 361-1749 or giftplanning@chla.usc.edu.

Please use my gift for the following purpose(s):

Children’s Hospital Los Angeles's greatest need (unrestricted)

Children’s Hospital Los Angeles's general endowment

Specific purpose or fund (Contact Steven Adamian, JD, at (323) 361-1749 or giftplanning@chla.usc.edu for details.)

Membership listing (please check one):

Please include my (and, if applicable, my spouse's) name in your society listings. Neither amount nor designation, if provided, will be included on the listing.

Please list me / us as follows:

I am honored to be included in your society; however, I prefer to remain anonymous. Please do not include my/our name in your society listings.

By signing this member profile, I reaffirm my commitment to Children’s Hospital Los Angeles. However, this letter shall not be binding upon my estate, and the information contained herein shall be used for Children’s Hospital Los Angeles purposes only.

Digital Signature

Digital Signature (Required)

Date Signed (Required)

Leave this field blank.

The information you share will be kept strictly confidential. By completing this form, you may receive communication and planned giving email news from Children’s Hospital Los Angeles. You can unsubscribe any time.

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Our Gift Planning team would be happy to speak with you in confidence, with no obligation.

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Federal tax ID number: 95-1690977

Information contained herein was accurate at the time of posting. The information on this website is not intended as legal or tax advice. For such advice, please consult an attorney or tax advisor. Figures cited in any examples are for illustrative purposes only. References to tax rates include federal taxes only and are subject to change. State law may further impact your individual results. California residents: Annuities are subject to regulation by the State of California. Payments under such agreements, however, are not protected or otherwise guaranteed by any government agency or the California Life and Health Insurance Guarantee Association. Oklahoma residents: A charitable gift annuity is not regulated by the Oklahoma Insurance Department and is not protected by a guaranty association affiliated with the Oklahoma Insurance Department. South Dakota residents: Charitable gift annuities are not regulated by and are not under the jurisdiction of the South Dakota Division of Insurance.

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