The Jean Remmel FitzSimmons Society — Member Profile Please fill out the form below to send us your Member Profile, so that we may welcome you into the Jean Remmel FitzSimmons Society. Please note: All highlighted and starred (*) fields are required. Name(s): * Age: Age (Spouse): Address: * City/State/Zip: * Country: Telephone: * E-Mail: * Choose Below: Southampton Hospital Foundation may include my (and, if applicable, my spouse's) name in the Jean Remmel FitzSimmons Society listings. (Neither amount nor designation, if provided, will be included on the listing.) I am honored to be included in the Jean Remmel FitzSimmons Society; however, I prefer to remain anonymous. Please do not include my/our name in the Jean Remmel FitzSimmons Society listings. Please share with us, in confidence, more about your estate provision for Southampton Hospital Foundation. The following information is optional. I have named Southampton Hospital Foundation as a beneficiary of my: Gifts Anyone Can Make Will or Trusts Appreciated Securities Life Insurance Retirement Plans Gifts That Pay You Income Charitable Gift Annuity Charitable Remainder Unitrusts Charitable Remainder Annuity Trusts Gifts That Protect Your Assets Charitable Lead Trust Retained Life Estate This provision is stated as a: Specific dollar amount ($): Percentage of estate/account (%): Based on Percentage: If based on a percentage, please estimate the current value of the gift to Southampton Hospital Foundation ($): My gift is: Unrestricted (General Operations) Designated for:
