STATEMENT OF INTENT

CARROLL HEALTH FOUNDATION

If you are interested in becoming a member of Carroll Health Foundation's Legacy Club or would like additional details, please complete the information below and return to Carroll Health Foundation. If you have any questions, please contact the Foundation office at (870) 423-5245.

(Please Print)

Name:_______________________________________________

Address:______________________________________________

City:__________________________________________________

Phone:(    )_________________  (    )________________
                         (Day)                              (Evening)

YES, I am including St. John's Hospital - Berryville in my Estate or Financial Plan. I understand that I may change my commitment at any time.

May we have permission to publish your name as a Legacy Club member?

Yes_____
No_____

My Attorney, CPA, or Trust Administrator's Name:

_______________________________________________________

____I'm not ready at this time to make a decision, but please keep me on your mailing list.

____I would like additional information and wish to be contacted.

_______________________________________________________
(Signature)                                                                (Date)