DBSA Legacy of Wellness Enrollment

DBSA Legacy of Wellness Society donors leave a legacy that provides hope, help, support, education, and life. Your planned gift will improve the lives of people who live with mood disorders―today, tomorrow, and far into the future. Your information will be confidential and you have the option to keep your membership anonymous.

Thank you for your lasting commitment to improving the lives of people living with mood disorders!

All information fields below are required and should be marked with an asterisk* unless noted as optional.

Your Information

We value your privacy and will not share your personal information.

First Name

Last Name

Street Number & Name

Unit, Apartment, Suite

City, Town

State, Province

Zip

Country
United States of America (USA)AfghanistanAlbaniaAlgeriaAndorraAngolaAnguillaAntigua & BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia & HerzegovinaBotswanaBrazilBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChina - Hong Kong / MacauColombiaComorosCongoCongo, Democratic Republic of (DRC)Costa RicaCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceFrench GuianaGabonGambiaGeorgiaGermanyGhanaGreat BritainGreeceGrenadaGuadeloupeGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIsrael and the Occupied TerritoriesItalyIvory Coast (Cote d'Ivoire)JamaicaJapanJordanKazakhstanKenyaKorea, Democratic Republic of (North Korea)Korea, Republic of (South Korea)KosovoKuwaitKyrgyz Republic (Kyrgyzstan)LaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedonia, Republic ofMadagascarMalawiMalaysiaMaldivesMaliMaltaMartiniqueMauritaniaMauritiusMayotteMexicoMoldova, Republic ofMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmar/BurmaNamibiaNepalNew ZealandNicaraguaNigerNigeriaNorwayOmanPacific IslandsPakistanPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarReunionRomaniaRussian FederationRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovak Republic (Slovakia)SloveniaSolomon IslandsSomaliaSouth AfricaSouth SudanSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTajikistanTanzaniaThailandNetherlandsTimor LesteTogoTrinidad & TobagoTunisiaTurkeyTurkmenistanTurks & Caicos IslandsUgandaUkraineUnited Arab EmiratesUnited States of America (USA)UruguayUzbekistanVenezuelaVietnamVirgin Islands (UK)Virgin Islands (US)YemenZambiaZimbabwe

Email

Phone Number

Date of Birth:

Yes, I would like to receive e-mail from Depression and Bipolar Support Alliance

Spousal Information

First Name

Last Name

Date of Birth:

Please tell us how you would like to be recognized.

You may recognize my/our gift by including my/our name(s) on the DBSA Legacy of Wellness Virtual Donor Wall.I/we wish my/our contribution to remain anonymous.

If you'd like to be recognized on the DBSA Legacy of Wellness Virtual Donor Wall, please list how you want your name(s) to appear.

Beneficiary Information

I have named DBSA as a beneficiary of my/our: (Select all that apply.)
Will/trustCharitable trustAnnuityLife insuranceIRA or retirement planOther
If you selected other, please specify.

Attorney’s Contact Information

Full Name:

Phone number:

Questions or Comments

Would you like someone to contact you to answer additional questions?
I/we have some additional questions. Please have a gift planning officer contact me.No, I do not require a follow-up phone call.

Additional Comments: