P
P.O. Box 50384 • Palo Alto, CA 94303-0384
Tel. 650-737-1368
Date: ___________________________
Donor Name: _______________________________________________
Address: _______________________________________________
City, State, Zip: _______________________________________________
Telephone: _______________________________________________
Brokerage Firm: _________________________________________
Brokerage Address _________________________________________
Brokerage City, State, Zip: _______________________________________
To Whom It May Concern,
This letter authorizes and directs you to transfer the following securities from my/our
account number: _________________________________________________
Security Name: ________________________________________
Security Symbol: __________________ Number of Shares: _______
To the account for the: Institute for Personal Change:
UBS Financial Services
2185 N. California Blvd., 4th Fl.
Post Office Box 8149
Walnut Creek, CA 94596-9943
Account Number KW 51070, DTC Num: 0221
Attn: Brian Sharpes, 925-937-1200 / 800-433-7992
________________________________ _______________________________
Owner 1 - Please Print Owner 2 - Please Print
________________________________ _______________________________
Signature Owner 1 Signature Owner 2
Thank your for donating to The Institute for Personal Change.
P.O. Box 50384 • Palo Alto, CA 94303-0384
Tel. 650-737-1368
Please follow these instructions to ensure your stock gift is processed accurately:
1. Please check all lines for accuracy.
2. Print Three Copies:
a. Retain one copy for your records,
b. Send one copy to your brokerage firm.
c. Mail or fax the third copy to:
Elaine Baskin, Executive Director Fax 650-856-6591
Institute for Personal Change
P.O. Box 50384
Palo Alto, CA 94303-0384
Please direct all transfer questions to:
UBS Financial Services 925-937-1200 / 800-433-7992
Brian Sharpes, CIMA
2185 N. California Blvd., 4th Fl.
Post Office Box 8149
Walnut Creek, CA 94596-9943
Please reference: Institute for Personal Change
Account Number: KW 51070
3. Please make sure your brokerage firm receives the form with your original signature.
4. If you wish to donate more than one type of securities, please print additional copies of this form.
IMPORTANT NOTE:
If you are making a donation of stock near the yearend, please be sure to call both The Institute for Personal Change and your Brokerage firm to ensure the stock is transferred before the new year. The value of your donation is calculated as of the actual date the securities transfer.
The Institute for Personal Change does not provide tax and/or legal advice. Please contact your CPA and/ or tax attorney for specific advice on tax strategies.
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