Jimmy Love Legacy Circle

Membership Form

I/we desire to provide for the future well-being of Muttville through a provision in my/our estate plans, and with this letter we are informing Muttville of our plans. I/we understand that this future commitment can be revoked or modified by me/us at any time.

Donor Name

Additional Donor Name (if applicable)

Address

City

State

Zip

Phone

Birthdate

I/we have made a provision to leave a legacy to Muttville through my/our:

Will Living Trust Retirement Plan or IRA Life Insurance Policy Other

Gift Value

Please contact me so I/we may inform Muttville, for long-term planning purposes only, of the current value of my/our future gift. (This amount is kept confidential.)

I/we understand that by stating an amount, my/our estate is not legally bound by the statement and that I/we may choose to add, subtract or revoke this bequest at any time, at my/our sole discretion.)

Digital Signature

Input your name(s) below to sign the form.

Signature

Add'l Signature (if applicable)

* Required