SAMPLE LETTER TO BROKER



SAMPLE LETTER TO BROKER

Date

Broker Name

Broker Address

Broker City, State, Zip

To Whom It May Concern:

Please accept this letter as authorization to transfer stock as a charitable contribution to the charity shown below:

|Number of shares: | |

|Name of issuing company: |(e.g., WellPoint, Inc.) |

|Specific share lot description/cost basis: |(i.e., indicate the original acquisition date and purchase price of the shares|

| |you wish to donate) |

|Expected date of transfer of shares designated to | |

|charity: | |

|Brokerage account number or SSN: | |

|Mailing address (home or work): | |

|Daytime phone number: | |

|Name of charity receiving shares: | |

|Charity address: | |

|Charity phone number: | |

|Name of charity’s stock broker: | |

|Charity’s broker DTC#: | |

|Charity’s brokerage account #: | |

|Donor(s): |(e.g., your name) |

I authorize (Broker name) to transfer the securities or cash as listed above. I understand that upon receiving this form, (Broker name) will cancel any open orders that will affect the transfer.

( ) This contribution relates to my 2011-2012 WellPoint Associate Giving Campaign pledge.

( ) This contribution relates to my 2012-2013 WellPoint Associate Giving Campaign pledge.

If you have any questions, please contact me at ___-___-____ or email WellPoint’s Associate Giving Campaign at AssociateGivingCampaign@.

Sincerely,

(Your Name)

cc: The WellPoint Associate Giving Campaign

Tiffany Etter, Program Manager, WellPoint Foundation

120 Monument Circle, Indianapolis, IN 46204 – or – Interoffice Mail: IN0103-A308

cc: Recipient Charity Name*

Street Address

City, State, Zip Code

Contact Name/Title (if known)

*Please forward an acknowledgement of this gift to me at the mailing address listed above.

IMPORTANT NOTES:

1. This form is provided as a sample template letter. You should consult with your attorney or tax advisor.

2. Confirm with your brokerage firm whether this letter needs to be notarized.

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