PHILANTHROPIC GIFT AGREEMENT
For
Jane and John Doe
We, Jane and John Doe, (“Donors”), hereby make a gift of $50,000.00 to NorthShore University HealthSystem
(“NorthShore”), a tax-exempt organization.
The gift will be paid over a maximum of five (5) years, according to the following schedule. Any failing to fully
fund the philanthropic gift within the agreed payment schedule will be considered a commitment upon the
Donor:
$ 10,000 - enclosed
$ 10,000 - by December 31, 2022
$ 10,000 - by December 31, 2023
$ 10,000 - by December 31, 2024
$ 10,000 - by December 31, 2025
The gift will be administered in accordance with the following provisions:
1. The use of the gift will be to provide support to the Center for XYZ at NorthShore and will be overseen by
Michael Smith, MD, Chief Scientific Officer, NorthShore Research Institute, and Melinda Jones, President,
NorthShore Evanston Hospital, or their successors as the institutional stewards. All funds will be
administered according to NorthShore policies.
2. Throughout the life of the gift, NorthShore Foundation will provide stewardship updates at least annually,
regarding the impact of the philanthropic support. For recognition purposes, Donors’ names may appear in
or on the NorthShore and NorthShore Foundation websites, annual report, NorthShore Foundation
publications, donor listings, and other public materials.
The Donors’ name should be written as:
________________________
3. If for some unforeseen reason NorthShore is no longer able to fulfill the gift intent of the Donors as
expressed in this Agreement, NorthShore reserves the right to re-direct funds to an alternative program
within NorthShore, keeping in mind the Donors’ original intent, and will first seek input from the Donors if
the Donors are living, willing, and able to provide input to NorthShore on the re-direction of funds.
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Philanthropic Gift Agreement for Jane and John Doe
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This Agreement represents the entire agreement of the parties with respect to the Donors’ gift and supersedes all
prior proposals, discussions, and agreements, and may not be amended except by a written agreement signed
and executed by both NorthShore and the Donors. This Agreement is governed by and will be construed in
accordance with the laws of the State of Illinois.
Signed: __________________________________________ Date:_______________________
Donor
Signed: __________________________________________ Date:_______________________
Donor
Gift accepted by NorthShore:
Signed: __________________________________________ Date:________________________
Executive Director
NorthShore Foundation
Signed: __________________________________________ Date:________________________
Chief Financial Officer
NorthShore University Health System
Checks should be made payable to NorthShore University HealthSystem.
According to the provisions of the Internal Revenue Code:
NorthShore is exempt from Federal income tax under section 501(c)(3),
NorthShore is classified as a 509(a)(1) Public Charity, and
Contributions to NorthShore are deductible under section 170.
The Federal Employer Identification number for NorthShore University HealthSystem is 12-3456789.
Mailing Address
NorthShore University HealthSystem Foundation
1033 University Place, Suite 450
Evanston, IL 60201
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