SHS SCHOLARSHIP FUND CHARITABLE BEQUEST INTENT
Name:_____________________________________________________________________________
Member Number:____________________________________________________________________
As evidence of my desire to provide a legacy of support for IIE’s Society for Health Systems (SHS), I
wish to inform SHS that you have been named in my estate plans as follows:

Bequest of approximate value $_______________ . If your gift is a percentage of your estate,
please indicate the approximate value of that percentage________%.

Life insurance benefits of approximate value $_______________
I designate this gift to be used for the SHS Scholarship Fund.
Thank you for your pledge. In recognition of your intention, we would like to acknowledge you by
publicizing your name on our donor list and including you in any future recognition activities.

Yes, you may publicize my name on the donor list, which serves as a motivation for others to
consider planned gifts in support of SHS.

I prefer my intentions to remain anonymous.
Donor Signature________________________________________________Date___________________
Address______________________________________________________________________________
Phone number (hm)________________________________(cell)________________________________
E-mail address________________________________________________________________________
Please fax to IIE at 770-441-3295 or mail to 3577 Parkway Lane, Suite 200, Norcross, GA 30092.