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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