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American Liver Foundation
39 Broadway, Suite 2700
New York, New York 10006

212-668-1000 Tel
212-483-8179 Fax

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Legacy Society Member Profile

Please fill in the fields below and click submit. Your profile information will not be shared with anyone and will be held in the strictest confidence.

* Required Fields
Full Name(s)*
Date of Birth
Date of Birth (spouse)
Street Address*
Zip Code*
Email Address*
Please designate whether you approve or not of displaying your name(s) in the Legacy Society listings*
Yes, include my (and, if applicable, my spouse's) name in the listings (amounts or designations not included) No, I/we prefer to remain anonymous – do not include my/our name in the listings
I have named the American Liver Foundation as a beneficiary of my (select all that apply):
Will / TrustIRA or Retirement Plan
Life Insurance PolicyCharitable Trust
Donor Advised FundOther
If other, please specify
Estate provision stated as:

Specific dollar amount ($)

Percentage of estate / account (%)

If based on a percentage, please estimate the current value of the gift to the American Liver Foundation
I approve of my gift being used for general operations (unrestricted use)
Orů I designate my gift to be used specifically for:

Page updated: October 4th, 2011