Vanderbilt University:

Bequest Documentation Form

Statement of Bequest Provision

If you have named Vanderbilt as a beneficiary of your estate, please let us know by filling out the form below. For more information about our gift annuity or charitable trust programs, please contact Anthony Barclay, Director of Planned Giving, directly at 615/936-5518 or Anthony.Barclay@vanderbilt.edu.

Full Name

Address

City

State

ZIP code

Phone number

Email address

VU degree and year

Type of Provision Estimated Amount

A. Outright bequest in my will of:

B. Portion of my estate for a value of:

C. Retirement plan beneficiary designation:

D. Life insurance policy:

E. Other (please describe)

Purpose

Please indicate specific purpose:

Unrestricted to Vanderbilt University

Unrestricted to my undergraduate school

Restricted for a specific purpose

Specific purpose: