Planning for the Future
Planning for the Future
“Planning for the Future” is designed to encourage you to think about how you want your assets to be distributed at death and assist you in gathering the information your attorney will need to prepare a will or trust that accomplishes your goals.
Consider a will provision A will assures your wishes will be fulfilled and your legacy established. Through your will, you may designate charitable bequests to express your philanthropic wishes. A bequest may be earmarked in a number of forms including: • A specific dollar amount • A percentage of your estate • A specific asset (real estate property, stocks, life insurance, etc…) When making a bequest to the Cooperstown Medical Center Foundation, gifts may be designated to an area you desire or left unrestricted to fund facility needs.
Plan a meaningful gift There are other options to providing a future gift through a will or trust arrangement. You may consider a planned gift of a different sort - one that may provide you income during your lifetime or one as simple as making a designation to the CMC Foundation on a beneficiary form. Planned gifts established through the Cooperstown Medical Center Foundation provide various tax advantages, may increase your income or provide an efficient transfer of assets to family members. Though your gift to benefit CMC does not become available until sometime in the future, the benefits you enjoy today will be significant and will help you fulfill your financial and philanthropic goals to ultimately benefit the Cooperstown Medical Center.
Types of planned gifts: • Charitable Remainder Trust (Unitrust and Annuity Trust): This gift option offers potential for increased income for you as well as mitigation or elimination of estate tax and capital gains tax liability. An annuity trust provides a fixed income stream for the duration of the trust while a unitrust distribution will vary depending on investment performance, thereby providing a valuable hedge against inflation. • Gift Annuity: The CMC Foundation, in exchange for a gift of acceptable assets of at least $10,000, agrees to pay up to two beneficiaries income for life. When the gift annuity matures, the balance of the contract is used to support the Cooperstown Medical Center. • Charitable Lead Trust: The CMC Foundation receives income for a term of years from the trust, and upon maturity, the trust’s principal either reverts to the donor or is transferred to others, such as family members. • Life Estate: With an irrevocable transfer to the CMC Foundation of a personal residence or farm in which you retain full use, a life estate gift is created. You receive an immediate income tax deduction and retain all benefits of conventional ownership. A life estate may help you reduce the size of your taxable estate and current income tax liability while providing a significant gift to ultimately benefit the Cooperstown Medical Center.
Family Information Full Name ________________________________________________________________________ Other names by which you are known __________________________________________________ Address__________________________________________________________________________ Phone (Home) ______________________ (Work) ____________________ Date of Birth ________________________ Birthplace _________________________________ Citizenship _____________________________ Social Security Number _____________________________________
Marital Status: Single Married Widowed Divorced Separated Information on previous marriages _____________________________________________________________
Full Name of Spouse ______________________________________________________________ Address __________________________________________________________________________ Phone (Home)_______________________ (Work) _______________________ Date of Birth ____________________________ Birthplace ______________________________Citizenship ________________________________ Social Security Number __________________________________________________
Marital Status: Single Married Widowed Divorced Separated Information on previous marriages _________________________________________________________________________________
Children and/or Other Dependents Child/Dependent #1 ___________________________________ Name ___________________________________ Relationship Date of Birth ___________________________________ Street Address ___________________________________ City State Zip
Child/Dependent #2 _____________________________________ Name _____________________________________ Relationship Date of Birth _____________________________________ Street Address _____________________________________ City State Zip
Child/Dependent #3 ___________________________________ Name ___________________________________ Relationship Date of Birth ___________________________________ Street Address ___________________________________ City State Zip
Child/Dependent #4 _____________________________________ Name _____________________________________ Relationship Date of Birth _____________________________________ Street Address _____________________________________ City State Zip
Child/Dependent #5 ___________________________________ Name ___________________________________ Relationship Date of Birth ___________________________________ Street Address ___________________________________ City State Zip
Child/Dependent #6 _____________________________________ Name _____________________________________ Relationship Date of Birth _____________________________________ Street Address _____________________________________ City State Zip
Does any child/dependent listed have special needs?
Yes
No
Personal Information Do you have a will?
Yes
No
If yes, what is the date of that will? _____________________________ Where is your will located/stored? ____________________________________________________ If available, provide your attorney with a copy of your will.
Do you have a trust? Yes No If yes, what is the date of that trust? _____________________________ Where is your trust agreement located/stored? ____________________________________________ If available, provide your attorney with a copy of your trust.
Do you have a safe deposit box? Yes No If yes, where is the safe deposit box located? ____________________________________________ Have you given durable power of attorney to anyone?
Yes
No
If yes, who is named as your power of attorney? _________________________________________ Where is your power of attorney located/stored? __________________________________________ If available, provide your attorney with a copy of your power of attorney.
Do you have a durable power of attorney for health care or advanced health care directive? Yes No If yes, who is named as your agent for health care decisions? _______________________________ Where is your health care document located/stored? ______________________________________ If available, provide your attorney with a copy of your health care document.
Financial Information: Assets Real Estate _________________________________________________________________________________ PARCEL #1 Description _____________________________________________________________________________________ Location _____________________________________________________________________________________ Nature of Ownership (name of individual, joint, or tenants-in-common) _____________________________________________________________________________________________
Date of Purchase
Cost
Current Value
_____________________________________________________________________________________ PARCEL #2 Description _____________________________________________________________________________________ Location _____________________________________________________________________________________ Nature of Ownership (name of individual, joint, or tenants-in-common) _____________________________________________________________________________________ Date of Purchase Cost Current Value
_____________________________________________________________________________________ PARCEL #3 Description _____________________________________________________________________________________ Location _____________________________________________________________________________________ Nature of Ownership (name of individual, joint, or tenants-in-common) _____________________________________________________________________________________ Date of Purchase Cost Current Value
_____________________________________________________________________________________ PARCEL #4 Description _____________________________________________________________________________________ Location _____________________________________________________________________________________ Nature of Ownership (name of individual, joint, or tenants-in-common) _____________________________________________________________________________________ Date of Purchase Cost Current Value Total Real Estate Value $ __________________
Stocks, Bonds, Mutual Funds _____________________________________________________________________________________ Company/Symbol/Account # _____________________________________________________________________________________ Nature of Ownership (name of individual, joint, or tenants-in-common) _____________________________________________________________________________________ Number of Shares/Units Date of Purchase _____________________________________________________________________________________ Cost Current Value _____________________________________________________________________________________ Company/Symbol/Account # _____________________________________________________________________________________ Nature of Ownership (name of individual, joint, or tenants-in-common) _____________________________________________________________________________________ Number of Shares/Units Date of Purchase _____________________________________________________________________________________ Cost Current Value _____________________________________________________________________________________ Company/Symbol/Account # _____________________________________________________________________________________ Nature of Ownership (name of individual, joint, or tenants-in-common) _____________________________________________________________________________________ Number of Shares/Units Date of Purchase _____________________________________________________________________________________ Cost Current Value
_____________________________________________________________________________________ Company/Symbol/Account # _____________________________________________________________________________________ Nature of Ownership (name of individual, joint, or tenants-in-common) _____________________________________________________________________________________ Number of Shares/Units Date of Purchase _____________________________________________________________________________________ Cost Current Value
_____________________________________________________________________________________ Company/Symbol/Account # _____________________________________________________________________________________ Nature of Ownership (name of individual, joint, or tenants-in-common) _____________________________________________________________________________________ Number of Shares/Units Date of Purchase _____________________________________________________________________________________ Cost Current Value Total Value of Stocks, Bonds, Mutual Funds $ ______________
Business Ownership (Proprietorship, Partnership, Corporation) Name of Business
Share of Ownership
Date of Creation
Purchase Cost
Current Value
________________________________________________ __________ ________________________________________________ __________ ________________________________________________ __________ ________________________________________________ __________
Total Value of Business Ownership Interests $ __________________
Other Investments Description/Cost
Nature of Ownership
Current Value
(Name of individual, joint, tenants-in-common)
____________________________________________________________
____________
____________________________________________________________
____________
____________________________________________________________
____________
____________________________________________________________
___________
Total Value of Other Investments $ _______________
Personal Property (Jewelry, Art, Furniture, Vehicles, etc.) _________________________________________________________________________________ ITEM #1 Description Location _____________________________________________________________________________________ Date of Purchase
Cost
Current Value
_________________________________________________________________________________ ITEM #2 Description Location _________________________________________________________________________________ Date of Purchase
Cost
Current Value
_________________________________________________________________________________ ITEM #3 Description Location _________________________________________________________________________________ Date of Purchase
Cost
Current Value
_________________________________________________________________________________ ITEM #4 Description Location _________________________________________________________________________________ Date of Purchase
Cost
Current Value
Total Personal Property Value $ _______________________
Other Assets/Notes Receivable Description/Cost
Current Value
___________________________________________ _________________________________ __________________________________________ _________________________________
Total Value of Other Assets/Notes Receivable $ _______________________
Bank or Savings Accounts Type (Checking or Savings)
Name of Institution
______________________
_____________________ _________
______________________
_____________________ _________
______________________
_____________________ _________
______________________
_____________________ _________
______________________
_____________________ _________
______________________
_____________________ _________ Total Bank or Savings Accounts $
Approximate Balance
______ ______
Insurance Policies POLICY #1 _____________________________________________________________________________________ Company Type of Policy Premium Payments (Amount & Frequency) _____________________________ Owner
_________________________ Beneficiary
___________________ Face Value Cash Value
POLICY #2 _____________________________________________________________________________________ Company Type of Policy Premium Payments (Amount & Frequency) _____________________________ Owner
_________________________ Beneficiary
_______________ Face ValueCash Value
POLICY #3 _____________________________________________________________________________________ Company Type of Policy Premium Payments (Amount & Frequency) _____________________________ Owner
_________________________ Beneficiary
___________________ Face Value Cash Value
Total Face Value of Insurance Policies $ _______________________
Retirement Accounts _____________________________________________________________________________________ Owner Plan Type (retirement, pension plan, profit sharing, etc...) _____________________________________________________________________________________ Account Number Plan Custodian
_____________________________________________________________________________________ Owner Plan Type (retirement, pension plan, profit sharing, etc...) _____________________________________________________________________________________ Account Number Plan Custodian
_____________________________________________________________________________________ Owner Plan Type (retirement, pension plan, profit sharing, etc...) _____________________________________________________________________________________ Account Number Plan Custodian
_____________________________________________________________________________________ Owner Plan Type (retirement, pension plan, profit sharing, etc...) _____________________________________________________________________________________ Account Number Plan Custodian
_____________________________________________________________________________________ Owner Plan Type (retirement, pension plan, profit sharing, etc...) _____________________________________________________________________________________ Account Number Plan Custodian
_____________________________________________________________________________________ Owner Plan Type (retirement, pension plan, profit sharing, etc...) _____________________________________________________________________________________ Account Number Plan Custodian
_____________________________________________________________________________________ Owner Plan Type (retirement, pension plan, profit sharing, etc...) _____________________________________________________________________________________ Account Number Plan Custodian
Annual Income Salary____________________________________________________________________________ Spouse’s Salary ____________________________________________________________________ Investment Income _________________________________________________________________ Other Income (list type and amount) __________________________________________________ Total Annual Income $ ________________________
Inheritance Do you expect to receive an inheritance?
Yes
No
If yes, explain. _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ ___________________________
Financial Information: Liabilities Mortgages, Trust Deeds, Loans, etc. Description
Terms
Current Outstanding Balance
_______________________________
______________________
_______________________________
______________________
_______________________________
______________________
_______________________________
______________________
_______________________________
______________________
_______________________________
______________________
Total Mortgages, Trust Deeds, Loans, etc. $_____________________
Other Debts Description Terms _____________________________________
Present Value _________________________________
_____________________________________
_________________________________
_____________________________________
_________________________________
_____________________________________
_________________________________
_____________________________________
_________________________________
_____________________________________
_________________________________
Total Other Debts $ ___________________________
Will Information Beneficiaries List the people, group and/or charitable organizations you want to benefit when you die.
_________________________________________________________________________________ Beneficiary #1 Name Address _____________________________________________________________________________________ Description of Gift (specific asset or amount)
________________________________________________________________________________ Beneficiary #2 Name Address _____________________________________________________________________________________ Description of Gift (specific asset or amount)
_________________________________________________________________________________ Beneficiary #3 Name Address _____________________________________________________________________________________ Description of Gift (specific asset or amount)
_________________________________________________________________________________ Beneficiary #4 Name Address _____________________________________________________________________________________ Description of Gift (specific asset or amount)
_________________________________________________________________________________ Beneficiary #5 Name Address _____________________________________________________________________________________ Description of Gift (specific asset or amount)
_________________________________________________________________________________ Beneficiary #6 Name Address _____________________________________________________________________________________ Description of Gift (specific asset or amount)
_________________________________________________________________________________ Beneficiary #7 Name Address _____________________________________________________________________________________ Description of Gift (specific asset or amount)
_____________________________________________________________________________________ Beneficiary #8 Name Address _____________________________________________________________________________________ Description of Gift (specific asset or amount)
_________________________________________________________________________________ Beneficiary #9 Name Address _____________________________________________________________________________________ Description of Gift (specific asset or amount)
Special instructions to be noted regarding the disposition of unique items: _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ ______________________________________________________
Executor Name someone you want to be in charge of carrying out the provisions of your will. This should be someone responsible and trustworthy. Be sure to select an alternate in case your primary choice is unable to serve. Executor
Alternate
___________________________________ Name
_____________________________________ Name
___________________________________ Street Address
____________________________________ Street Address
___________________________________ City State Zip
____________________________________ City State Zip
Guardian If both you and your spouse die while you have minor children, who would you want to appoint as guardian of those children? You may select separate people to be in charge of the children’s physical and financial well-being. Be sure to select an alternate in case your primary choice is unable to serve. Guardian
Alternate
_________________________________ Name
_____________________________________ Name
_________________________________ Street Address
_____________________________________ Street Address
_________________________________ City State Zip
_____________________________________ City State Zip
Sample Language When including the Cooperstown Medical Center Foundation in your will, consider the following language to ensure your gift is appropriately designated.
Specific Dollar Amount or Estate Percentage “I give, devise and bequeath to the Cooperstown Medical Center Foundation, 1200 Roberts Ave NE Cooperstown, ND 58425, a non-profit charitable corporation under the laws of the State of North Dakota, (Tax ID #45-0450301) the sum of $ _____________________ or _______ percent of the value of my estate to be used for … (note desired gift designation)”
Real Estate “I give, devise and bequeath to the Cooperstown Medical Center Foundation, 1200 Roberts Ave. NE Cooperstown, ND 58425, a non-profit charitable corporation under the laws of the State of North Dakota, (Tax ID #45-0450301) the following real property described as _______________________, situated in ____________________________County, State of ______________________________, to use the said property and the rents, income, or proceeds arising therefrom or the proceeds of the sale thereof, for … (note desired gift designation).”
Residue of Your Estate “All the rest, residue and remainder of my estate, both real and personal, I give, devise and bequeath to the Cooperstown Medical Center Foundation, 1200 Roberts Ave NE Cooperstown, ND 58425, a non-profit charitable corporation under the laws of the State of North Dakota, (Tax ID #45-0450301) to be used for … (note desired gift designation).”
Trust Information Trustee Name someone you want to be in charge of carrying out the provisions of your trust. This should be someone responsible and trustworthy. Be sure to select an alternate in case your primary choice is unable to serve. You may name the same (or different) people as executor and trustee.
Trustee
Alternate
_________________________________ Name
_____________________________________ Name
__________________________________ Street Address
____________________________________ Street Address
__________________________________ City State Zip
____________________________________ City State Zip
Briefly describe what you would like a trust to accomplish for you. _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _______________________________________________________________
Terms of Trust General Instructions: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________
Income distribution as follows: Name________________________________________________________________________________
Name________________________________________________________________________________
Name________________________________________________________________________________
Name________________________________________________________________________________
Name________________________________________________________________________________
Name________________________________________________________________________________
Principal distribution as follows: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Instructions regarding termination of this trust: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________
Trust Principal Which of the assets you listed do you want to include in your trust? If you aren’t sure, this is an issue to discuss with your attorney.
Insurance Policies (Description and Amount) _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________
Real Property (Description) _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________
Stocks (Description) _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________
Other Property (Description) _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________
leave a legacy We recognize and honor donors who have confirmed testamentary gifts with the Cooperstown Medical Center Foundation for the benefit of the Cooperstown Medical Center. _______________________________________ Name
__________________________________________________ Second Name (if joint gift)
_____________________________________________________________________________________________ Address City State Zip _____________________________________________________________________________________________ Home Phone Work/Cell Phone E-mail Address
Yes, it is my/our intent to leave a legacy by naming the Cooperstown Medical Center Foundation as a primary beneficiary through my/our: Will Living Trust Life Insurance Plan Retirement Plan, e.g., 401(k), IRA Charitable Remainder Trust* Employee Stock Option Plan (ESOP) Other _____________________________ I/we wish to inform the Cooperstown Medical Center Foundation, that as of this date, the current value of my/our estate gift is: $ ________________________ ,** however, I/we may choose to modify or revoke this provision at any time. I/we will notify the Cooperstown Medical Center Foundation if provisions are changed. (If your gift is a percentage of your estate, please indicate the present value of that percentage.) We would like our gift to be used:
where the need is greatest as a gift to benefit the following ______________________
The Cooperstown Medical Center Foundation appreciates the opportunity to recognize your testamentary gift and honor your spirit of philanthropy in donor recognition listings. Please indicate here if you choose to opt out of such listings. ____________________________________________________________________________________ Signature Date _____________________________________________________________________________________ Signature Date * If your CRT beneficiary designation is irrevocable, please enclose a copy of the trust document and a statement from the financial institution. ** We hope you will share the approximate amount of your gift with us so the medical center will know of your generosity and we can recognize you appropriately. It is also helpful for us to have supporting documentation on file. Please attach if possible. The details of your testamentary gift remain confidential. The Cooperstown Medical Center Foundation is organized as a North Dakota nonprofit corporation, is exempted from federal income tax liability by Internal Revenue Code Section 501(c)(3), and qualifies as a public charity under Internal Revenue Code Section 509.
1200 Roberts Ave NE Cooperstown, ND 58425 701-797-2221 ext 7108 [email protected] www.coopermc.com
“Planning for the Future” is designed to encourage you to think about how you want your assets to be distributed at death and assist you in gathering the information your attorney will need to prepare a will or trust that accomplishes your goals.
Consider a will provision A will assures your wishes will be fulfilled and your legacy established. Through your will, you may designate charitable bequests to express your philanthropic wishes. A bequest may be earmarked in a number of forms including: • A specific dollar amount • A percentage of your estate • A specific asset (real estate property, stocks, life insurance, etc…) When making a bequest to the Cooperstown Medical Center Foundation, gifts may be designated to an area you desire or left unrestricted to fund facility needs.
Plan a meaningful gift There are other options to providing a future gift through a will or trust arrangement. You may consider a planned gift of a different sort - one that may provide you income during your lifetime or one as simple as making a designation to the CMC Foundation on a beneficiary form. Planned gifts established through the Cooperstown Medical Center Foundation provide various tax advantages, may increase your income or provide an efficient transfer of assets to family members. Though your gift to benefit CMC does not become available until sometime in the future, the benefits you enjoy today will be significant and will help you fulfill your financial and philanthropic goals to ultimately benefit the Cooperstown Medical Center.
Types of planned gifts: • Charitable Remainder Trust (Unitrust and Annuity Trust): This gift option offers potential for increased income for you as well as mitigation or elimination of estate tax and capital gains tax liability. An annuity trust provides a fixed income stream for the duration of the trust while a unitrust distribution will vary depending on investment performance, thereby providing a valuable hedge against inflation. • Gift Annuity: The CMC Foundation, in exchange for a gift of acceptable assets of at least $10,000, agrees to pay up to two beneficiaries income for life. When the gift annuity matures, the balance of the contract is used to support the Cooperstown Medical Center. • Charitable Lead Trust: The CMC Foundation receives income for a term of years from the trust, and upon maturity, the trust’s principal either reverts to the donor or is transferred to others, such as family members. • Life Estate: With an irrevocable transfer to the CMC Foundation of a personal residence or farm in which you retain full use, a life estate gift is created. You receive an immediate income tax deduction and retain all benefits of conventional ownership. A life estate may help you reduce the size of your taxable estate and current income tax liability while providing a significant gift to ultimately benefit the Cooperstown Medical Center.
Family Information Full Name ________________________________________________________________________ Other names by which you are known __________________________________________________ Address__________________________________________________________________________ Phone (Home) ______________________ (Work) ____________________ Date of Birth ________________________ Birthplace _________________________________ Citizenship _____________________________ Social Security Number _____________________________________
Marital Status: Single Married Widowed Divorced Separated Information on previous marriages _____________________________________________________________
Full Name of Spouse ______________________________________________________________ Address __________________________________________________________________________ Phone (Home)_______________________ (Work) _______________________ Date of Birth ____________________________ Birthplace ______________________________Citizenship ________________________________ Social Security Number __________________________________________________
Marital Status: Single Married Widowed Divorced Separated Information on previous marriages _________________________________________________________________________________
Children and/or Other Dependents Child/Dependent #1 ___________________________________ Name ___________________________________ Relationship Date of Birth ___________________________________ Street Address ___________________________________ City State Zip
Child/Dependent #2 _____________________________________ Name _____________________________________ Relationship Date of Birth _____________________________________ Street Address _____________________________________ City State Zip
Child/Dependent #3 ___________________________________ Name ___________________________________ Relationship Date of Birth ___________________________________ Street Address ___________________________________ City State Zip
Child/Dependent #4 _____________________________________ Name _____________________________________ Relationship Date of Birth _____________________________________ Street Address _____________________________________ City State Zip
Child/Dependent #5 ___________________________________ Name ___________________________________ Relationship Date of Birth ___________________________________ Street Address ___________________________________ City State Zip
Child/Dependent #6 _____________________________________ Name _____________________________________ Relationship Date of Birth _____________________________________ Street Address _____________________________________ City State Zip
Does any child/dependent listed have special needs?
Yes
No
Personal Information Do you have a will?
Yes
No
If yes, what is the date of that will? _____________________________ Where is your will located/stored? ____________________________________________________ If available, provide your attorney with a copy of your will.
Do you have a trust? Yes No If yes, what is the date of that trust? _____________________________ Where is your trust agreement located/stored? ____________________________________________ If available, provide your attorney with a copy of your trust.
Do you have a safe deposit box? Yes No If yes, where is the safe deposit box located? ____________________________________________ Have you given durable power of attorney to anyone?
Yes
No
If yes, who is named as your power of attorney? _________________________________________ Where is your power of attorney located/stored? __________________________________________ If available, provide your attorney with a copy of your power of attorney.
Do you have a durable power of attorney for health care or advanced health care directive? Yes No If yes, who is named as your agent for health care decisions? _______________________________ Where is your health care document located/stored? ______________________________________ If available, provide your attorney with a copy of your health care document.
Financial Information: Assets Real Estate _________________________________________________________________________________ PARCEL #1 Description _____________________________________________________________________________________ Location _____________________________________________________________________________________ Nature of Ownership (name of individual, joint, or tenants-in-common) _____________________________________________________________________________________________
Date of Purchase
Cost
Current Value
_____________________________________________________________________________________ PARCEL #2 Description _____________________________________________________________________________________ Location _____________________________________________________________________________________ Nature of Ownership (name of individual, joint, or tenants-in-common) _____________________________________________________________________________________ Date of Purchase Cost Current Value
_____________________________________________________________________________________ PARCEL #3 Description _____________________________________________________________________________________ Location _____________________________________________________________________________________ Nature of Ownership (name of individual, joint, or tenants-in-common) _____________________________________________________________________________________ Date of Purchase Cost Current Value
_____________________________________________________________________________________ PARCEL #4 Description _____________________________________________________________________________________ Location _____________________________________________________________________________________ Nature of Ownership (name of individual, joint, or tenants-in-common) _____________________________________________________________________________________ Date of Purchase Cost Current Value Total Real Estate Value $ __________________
Stocks, Bonds, Mutual Funds _____________________________________________________________________________________ Company/Symbol/Account # _____________________________________________________________________________________ Nature of Ownership (name of individual, joint, or tenants-in-common) _____________________________________________________________________________________ Number of Shares/Units Date of Purchase _____________________________________________________________________________________ Cost Current Value _____________________________________________________________________________________ Company/Symbol/Account # _____________________________________________________________________________________ Nature of Ownership (name of individual, joint, or tenants-in-common) _____________________________________________________________________________________ Number of Shares/Units Date of Purchase _____________________________________________________________________________________ Cost Current Value _____________________________________________________________________________________ Company/Symbol/Account # _____________________________________________________________________________________ Nature of Ownership (name of individual, joint, or tenants-in-common) _____________________________________________________________________________________ Number of Shares/Units Date of Purchase _____________________________________________________________________________________ Cost Current Value
_____________________________________________________________________________________ Company/Symbol/Account # _____________________________________________________________________________________ Nature of Ownership (name of individual, joint, or tenants-in-common) _____________________________________________________________________________________ Number of Shares/Units Date of Purchase _____________________________________________________________________________________ Cost Current Value
_____________________________________________________________________________________ Company/Symbol/Account # _____________________________________________________________________________________ Nature of Ownership (name of individual, joint, or tenants-in-common) _____________________________________________________________________________________ Number of Shares/Units Date of Purchase _____________________________________________________________________________________ Cost Current Value Total Value of Stocks, Bonds, Mutual Funds $ ______________
Business Ownership (Proprietorship, Partnership, Corporation) Name of Business
Share of Ownership
Date of Creation
Purchase Cost
Current Value
________________________________________________ __________ ________________________________________________ __________ ________________________________________________ __________ ________________________________________________ __________
Total Value of Business Ownership Interests $ __________________
Other Investments Description/Cost
Nature of Ownership
Current Value
(Name of individual, joint, tenants-in-common)
____________________________________________________________
____________
____________________________________________________________
____________
____________________________________________________________
____________
____________________________________________________________
___________
Total Value of Other Investments $ _______________
Personal Property (Jewelry, Art, Furniture, Vehicles, etc.) _________________________________________________________________________________ ITEM #1 Description Location _____________________________________________________________________________________ Date of Purchase
Cost
Current Value
_________________________________________________________________________________ ITEM #2 Description Location _________________________________________________________________________________ Date of Purchase
Cost
Current Value
_________________________________________________________________________________ ITEM #3 Description Location _________________________________________________________________________________ Date of Purchase
Cost
Current Value
_________________________________________________________________________________ ITEM #4 Description Location _________________________________________________________________________________ Date of Purchase
Cost
Current Value
Total Personal Property Value $ _______________________
Other Assets/Notes Receivable Description/Cost
Current Value
___________________________________________ _________________________________ __________________________________________ _________________________________
Total Value of Other Assets/Notes Receivable $ _______________________
Bank or Savings Accounts Type (Checking or Savings)
Name of Institution
______________________
_____________________ _________
______________________
_____________________ _________
______________________
_____________________ _________
______________________
_____________________ _________
______________________
_____________________ _________
______________________
_____________________ _________ Total Bank or Savings Accounts $
Approximate Balance
______ ______
Insurance Policies POLICY #1 _____________________________________________________________________________________ Company Type of Policy Premium Payments (Amount & Frequency) _____________________________ Owner
_________________________ Beneficiary
___________________ Face Value Cash Value
POLICY #2 _____________________________________________________________________________________ Company Type of Policy Premium Payments (Amount & Frequency) _____________________________ Owner
_________________________ Beneficiary
_______________ Face ValueCash Value
POLICY #3 _____________________________________________________________________________________ Company Type of Policy Premium Payments (Amount & Frequency) _____________________________ Owner
_________________________ Beneficiary
___________________ Face Value Cash Value
Total Face Value of Insurance Policies $ _______________________
Retirement Accounts _____________________________________________________________________________________ Owner Plan Type (retirement, pension plan, profit sharing, etc...) _____________________________________________________________________________________ Account Number Plan Custodian
_____________________________________________________________________________________ Owner Plan Type (retirement, pension plan, profit sharing, etc...) _____________________________________________________________________________________ Account Number Plan Custodian
_____________________________________________________________________________________ Owner Plan Type (retirement, pension plan, profit sharing, etc...) _____________________________________________________________________________________ Account Number Plan Custodian
_____________________________________________________________________________________ Owner Plan Type (retirement, pension plan, profit sharing, etc...) _____________________________________________________________________________________ Account Number Plan Custodian
_____________________________________________________________________________________ Owner Plan Type (retirement, pension plan, profit sharing, etc...) _____________________________________________________________________________________ Account Number Plan Custodian
_____________________________________________________________________________________ Owner Plan Type (retirement, pension plan, profit sharing, etc...) _____________________________________________________________________________________ Account Number Plan Custodian
_____________________________________________________________________________________ Owner Plan Type (retirement, pension plan, profit sharing, etc...) _____________________________________________________________________________________ Account Number Plan Custodian
Annual Income Salary____________________________________________________________________________ Spouse’s Salary ____________________________________________________________________ Investment Income _________________________________________________________________ Other Income (list type and amount) __________________________________________________ Total Annual Income $ ________________________
Inheritance Do you expect to receive an inheritance?
Yes
No
If yes, explain. _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ ___________________________
Financial Information: Liabilities Mortgages, Trust Deeds, Loans, etc. Description
Terms
Current Outstanding Balance
_______________________________
______________________
_______________________________
______________________
_______________________________
______________________
_______________________________
______________________
_______________________________
______________________
_______________________________
______________________
Total Mortgages, Trust Deeds, Loans, etc. $_____________________
Other Debts Description Terms _____________________________________
Present Value _________________________________
_____________________________________
_________________________________
_____________________________________
_________________________________
_____________________________________
_________________________________
_____________________________________
_________________________________
_____________________________________
_________________________________
Total Other Debts $ ___________________________
Will Information Beneficiaries List the people, group and/or charitable organizations you want to benefit when you die.
_________________________________________________________________________________ Beneficiary #1 Name Address _____________________________________________________________________________________ Description of Gift (specific asset or amount)
________________________________________________________________________________ Beneficiary #2 Name Address _____________________________________________________________________________________ Description of Gift (specific asset or amount)
_________________________________________________________________________________ Beneficiary #3 Name Address _____________________________________________________________________________________ Description of Gift (specific asset or amount)
_________________________________________________________________________________ Beneficiary #4 Name Address _____________________________________________________________________________________ Description of Gift (specific asset or amount)
_________________________________________________________________________________ Beneficiary #5 Name Address _____________________________________________________________________________________ Description of Gift (specific asset or amount)
_________________________________________________________________________________ Beneficiary #6 Name Address _____________________________________________________________________________________ Description of Gift (specific asset or amount)
_________________________________________________________________________________ Beneficiary #7 Name Address _____________________________________________________________________________________ Description of Gift (specific asset or amount)
_____________________________________________________________________________________ Beneficiary #8 Name Address _____________________________________________________________________________________ Description of Gift (specific asset or amount)
_________________________________________________________________________________ Beneficiary #9 Name Address _____________________________________________________________________________________ Description of Gift (specific asset or amount)
Special instructions to be noted regarding the disposition of unique items: _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ ______________________________________________________
Executor Name someone you want to be in charge of carrying out the provisions of your will. This should be someone responsible and trustworthy. Be sure to select an alternate in case your primary choice is unable to serve. Executor
Alternate
___________________________________ Name
_____________________________________ Name
___________________________________ Street Address
____________________________________ Street Address
___________________________________ City State Zip
____________________________________ City State Zip
Guardian If both you and your spouse die while you have minor children, who would you want to appoint as guardian of those children? You may select separate people to be in charge of the children’s physical and financial well-being. Be sure to select an alternate in case your primary choice is unable to serve. Guardian
Alternate
_________________________________ Name
_____________________________________ Name
_________________________________ Street Address
_____________________________________ Street Address
_________________________________ City State Zip
_____________________________________ City State Zip
Sample Language When including the Cooperstown Medical Center Foundation in your will, consider the following language to ensure your gift is appropriately designated.
Specific Dollar Amount or Estate Percentage “I give, devise and bequeath to the Cooperstown Medical Center Foundation, 1200 Roberts Ave NE Cooperstown, ND 58425, a non-profit charitable corporation under the laws of the State of North Dakota, (Tax ID #45-0450301) the sum of $ _____________________ or _______ percent of the value of my estate to be used for … (note desired gift designation)”
Real Estate “I give, devise and bequeath to the Cooperstown Medical Center Foundation, 1200 Roberts Ave. NE Cooperstown, ND 58425, a non-profit charitable corporation under the laws of the State of North Dakota, (Tax ID #45-0450301) the following real property described as _______________________, situated in ____________________________County, State of ______________________________, to use the said property and the rents, income, or proceeds arising therefrom or the proceeds of the sale thereof, for … (note desired gift designation).”
Residue of Your Estate “All the rest, residue and remainder of my estate, both real and personal, I give, devise and bequeath to the Cooperstown Medical Center Foundation, 1200 Roberts Ave NE Cooperstown, ND 58425, a non-profit charitable corporation under the laws of the State of North Dakota, (Tax ID #45-0450301) to be used for … (note desired gift designation).”
Trust Information Trustee Name someone you want to be in charge of carrying out the provisions of your trust. This should be someone responsible and trustworthy. Be sure to select an alternate in case your primary choice is unable to serve. You may name the same (or different) people as executor and trustee.
Trustee
Alternate
_________________________________ Name
_____________________________________ Name
__________________________________ Street Address
____________________________________ Street Address
__________________________________ City State Zip
____________________________________ City State Zip
Briefly describe what you would like a trust to accomplish for you. _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _______________________________________________________________
Terms of Trust General Instructions: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________
Income distribution as follows: Name________________________________________________________________________________
Name________________________________________________________________________________
Name________________________________________________________________________________
Name________________________________________________________________________________
Name________________________________________________________________________________
Name________________________________________________________________________________
Principal distribution as follows: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Instructions regarding termination of this trust: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________
Trust Principal Which of the assets you listed do you want to include in your trust? If you aren’t sure, this is an issue to discuss with your attorney.
Insurance Policies (Description and Amount) _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________
Real Property (Description) _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________
Stocks (Description) _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________
Other Property (Description) _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________
leave a legacy We recognize and honor donors who have confirmed testamentary gifts with the Cooperstown Medical Center Foundation for the benefit of the Cooperstown Medical Center. _______________________________________ Name
__________________________________________________ Second Name (if joint gift)
_____________________________________________________________________________________________ Address City State Zip _____________________________________________________________________________________________ Home Phone Work/Cell Phone E-mail Address
Yes, it is my/our intent to leave a legacy by naming the Cooperstown Medical Center Foundation as a primary beneficiary through my/our: Will Living Trust Life Insurance Plan Retirement Plan, e.g., 401(k), IRA Charitable Remainder Trust* Employee Stock Option Plan (ESOP) Other _____________________________ I/we wish to inform the Cooperstown Medical Center Foundation, that as of this date, the current value of my/our estate gift is: $ ________________________ ,** however, I/we may choose to modify or revoke this provision at any time. I/we will notify the Cooperstown Medical Center Foundation if provisions are changed. (If your gift is a percentage of your estate, please indicate the present value of that percentage.) We would like our gift to be used:
where the need is greatest as a gift to benefit the following ______________________
The Cooperstown Medical Center Foundation appreciates the opportunity to recognize your testamentary gift and honor your spirit of philanthropy in donor recognition listings. Please indicate here if you choose to opt out of such listings. ____________________________________________________________________________________ Signature Date _____________________________________________________________________________________ Signature Date * If your CRT beneficiary designation is irrevocable, please enclose a copy of the trust document and a statement from the financial institution. ** We hope you will share the approximate amount of your gift with us so the medical center will know of your generosity and we can recognize you appropriately. It is also helpful for us to have supporting documentation on file. Please attach if possible. The details of your testamentary gift remain confidential. The Cooperstown Medical Center Foundation is organized as a North Dakota nonprofit corporation, is exempted from federal income tax liability by Internal Revenue Code Section 501(c)(3), and qualifies as a public charity under Internal Revenue Code Section 509.
1200 Roberts Ave NE Cooperstown, ND 58425 701-797-2221 ext 7108 [email protected] www.coopermc.com
