SUSTAINING PARTNERS PROGRAM

Philanthropic Investment Agreement

Please complete all sections of the agreement and return it with your contribution. Organization name: Contact name: Title: Mailing address:

Phone: (W) (C) Email: For recognition purposes, please indicate exactly how you would like your name to appear:

Check here if you would prefer to remain anonymous.

Please choose your level of support. Sustaining Partnership $7,500 contribution $2,500 contribution $5,000 contribution $1,000 contribution

Please designate your gift commitment:

$______MedStar Health: Area of greatest need $______MedStar National Rehabilitation Hospital

$______MedStar Franklin Square Medical Center $______MedStar Patient Safety Institute

$______MedStar Hospital $______MedStar Southern Hospital Center

$______MedStar Good Samaritan Hospital $______MedStar St. Mary’s Hospital

$______MedStar Harbor Hospital $______MedStar Union Memorial Hospital

$______MedStar Health Research Institute $______MedStar Visiting Nurse Association

$______MedStar Institute for Innovation $______MedStar Washington Hospital Center

$______MedStar Montgomery Medical Center

(continued on next page) Philanthropic Investment Agreement Our organization will fulfill this corporate partnership commitment as follows: CHECK: Please make checks payable to: MedStar Health (Note the Sustaining Partners Program)

CREDIT CARD: * Visa * MasterCard * American Express * Discover *You may also give securely online at MedStarHealth.org/SustainingPartners. Name on the card: Credit card #: Expiration Date: / For a contribution of $ CID#: Address of card holder, including ZIP code:

INVOICE: Invoice instructions:

Thank you for your partnership with MedStar Health. We will provide a receipt for tax purposes after an annual contribution payment has been made.

Signature Date

Signature – MedStar Philanthropy Date

We will provide you with a copy of the signed Philanthropic Investment Agreement. Please return to: Megan Long, Manager, Sustained Giving MedStar Health Philanthropy 5565 Sterrett Place, Fourth Floor Columbia, MD 21044 410-772-6670 PHONE [email protected] EMAIL

Note: Contributions are graciously accepted for charitable purposes that intend to promote better health care, benefit society and/or demonstrate good corporate citizenship. Donations may not be linked, implicitly or explicitly, to any expectation or agreement that MedStar Health will use, order, recommend, or make a referral for any product or service and may not result in a personal benefit to any individual, corporation, foundation, or organization.

SUSTAINING PARTNERS PROGRAM 14-MHP-0950.042014