Stock Transfer Notification Form

Thank you for your interest in completing this notification form to let PIH Health Foundation know of your intent to transfer a gift of stock. You will be required to initiate the transfer with your broker and complete any necessary forms with your financial institution.

* Required fields

Personal Information

Donor Name

Address

Phone

How Would You Like Your Gift to Impact?

Greatest need

Option 1

Option 2

Option 3

Option 4

Option 5

Choose a Gift Type

Stock

Mutual Fund

Gift of mutual form opened below

Gift of stock form opened below

For gifts of stock:

Broker Name

Broker's Institution

Broker's Phone

Broker's Email

Stock Name/Ticker Symbol

Number of Shares

Expected Date of Transfer

For gifts of mutual fund:

Please contact us for more information on a transfer of mutual funds. We will do our best to assist you with instructions for this gift.

Name of Mutual Fund:

Organization's Information

Organization's Legal Name:

Organization's Tax ID:

Organization's Address: 12401 Washington Blvd., Whittier, CA 90602

Organization's Email:

Organization's Phone Number:

Organization's Broker Institution:

Organization's Broker Institution Address:

Organization's Account Name:

Organization's Brokerage Account Number:

Organization's Electronic Transfer Number (DTC):

Instructions for transfers by certified mail - If you hold securities in certificate form, you will need to mail two envelopes separately to complete your gift. In the first envelope, place the unsigned stock certificate(s). In the other envelope, include a signed stock power for each certificate. You may obtain this power from your broker or bank. Please remember to use certified mail.

Please note: This notification form is not a receipt for your charitable donation. We will send you an acknowledgement after we have received your gift. The value of a charitable gift of stock is determined by the average between the high and low stock price on the date of the gift. Mutual fund shares are valued using the closing price for the fund on the date of the gift. The date of the gift is the date the charitable organization receives the asset. Consult your broker for more information on the timing of the transfer.

Planned Giving, Lifesaving Impact.