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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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