LIONS EYE FOUNDATION OF CALIFORNIA-NEVADA, INC.

[Pages:1]LIONS EYE FOUNDATION OF CALIFORNIA-NEVADA, INC.

(a non-profit, 501(c)3 charitable corporation)

BENEFICIARY DESIGNATION (For IRA, 401K, Estates and Trusts)

(Notification of Donor(s) inclusion of Lions Eye Foundation of California-Nevada, Inc. in donor's estate planning)

OUR MISSION: "The Lions Eye Foundation preserves & restores the gift of sight by providing free ophthalmic examinations, operations & medications to the less fortunate members of our community."

(Providing only GENERAL information regarding the community support we have received helps us plan for the future. Please tell us about any recent gifts.)

1. Type of Gift

As a beneficiary in a Retirement Plan. As a beneficiary in a will or living trust (specific, residual or contingent). As a beneficiary in a Charitable Remainder Trust or Charitable Lead Trust. As a beneficiary in a Life Insurance Policy or in a manner not named above. Please specify.

2. Estimated value to the Lions Eye Foundation. (optional)

3. Date of Donor's birth

4. Gift is to be used by the Lions Eye Foundation:

In such manner as its mission may determine Building and Equipment Fund

5. In regards to listing donor(s) name as a member of the Future Vision Society donor recognition program together with a handsome lapel pin (there is no cost for membership).

I would like my name to appear as

Please do not list my name. The commitment should appear "Anonymous."

I trust this information will be held in the strictest confidence and utilized only for estimating the value of future gifts for use in fighting blindness and providing free ophthalmic examinations, operations and medications to the less fortunate members of our community. It is understood that this Beneficiary Designation is not legally binding and that the future gift to the Lions Eye Foundation of California-Nevada, Inc. may be changed at any time without notice.

Donor Signature

Date

Address

Print Name

City, State, Zip Code Please send form to: P.O. Box 7999, San Francisco, CA 94120 or lionseyefoundation@

Phone

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