SECURITIES TRANSFER FORM The Cancer Research Foundation is a 501(c)3, Tax-Exempt, Public Charity that accepts most securities including but not limited to Stocks, Bonds and Mutual Funds. Please accept this request as authorization for irrevocable transfer of the following securities from my account to the Cancer Research Foundation a charity account. Donor Information (please print or type) Name Address City, State and Zip Telephone E-Mail
Securities Pledge Information Please accept this request as authorization for irrevocable transfer of the following securities from my account to the Cancer Research Foundation a charity account. (For additional securities please use back) Name of security:
Symbol:
Number of shares:
Name of security:
Symbol:
Number of shares:
Certificate and DTC Transfer Information The most convenient way to transfer securities to our charity is DTC transfer. Simply instruct your broker to electronically transfer securities to the Cancer Research Foundation Scottrade Account using the info below. The other option for transfer is to mail the signed certificates and this form to the info below: DTC Transfer Information Brokerage firm: Scottrade Account name: Cancer Research Foundation Account number: 20232522 DTC number: 0705
Certificate Mailing Information Cancer Research Foundation Attn: Estate Planning 2764 N Green Valley Pkwy, Ste 329, Henderson, NV 89016 Tax ID #16-1726937
Authorization: I understand that in exchange for this donation no goods or services were provided. Please accept this request as an authorization for irrevocable transfer of the following securities from my account to the Cancer Research Foundation charity account. Signature:
Date:
SEND A COPY OF THIS FORM TO (via email or mail):
[email protected] Cancer Research Foundation, 2764 N Green Valley Pkwy, Ste 329, Henderson, NV 89014 Cancer Research Foundation – a 501(c)3, Tax-Exempt, Public Charity 2764 N Green Valley Pkwy, Ste 329, Henderson, NV 89014 – CancerResearchFoundation.org – 800-You-Cure