Securities Transfer Form - Siloam Mission [PDF]

To be completed by Donor: Name of Donor: Day time telephone: Address of Donor: Delivering Institution: Address of Delive

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Securities Transfer Form To be completed by Donor: Name of Donor: ____________________________ Day time telephone:___________________ Address of Donor: ________________________________________________________ Delivering Institution: ______________________________________________ Address of Delivering Institution: _____________________________________ Account # at Delivering Institution: ____________________________________ Name of Security: ______________________ # of shares:_________________________ Approximate Value of each share: $_________ Approximate Total Value: $_____________ Date of Transfer to Siloam Mission’s Account: ___________________________ This letter will serve as your authorization to release the securities noted above to the account of Siloam Mission Inc. I understand that I will receive a Gift-In-Kind tax receipt from Siloam Mission Inc. within approximately 2 weeks, for the closing price of these securities on the date of transfer to Siloam Mission Inc.’s account at CIBC Wood Gundy (711 079 77). These securities have been donated to Siloam Mission Inc. without restriction and can be sold by Siloam Mission Inc. at any time. __________________________________ Signature of Donor

__________________________

Date

Receiving Institution Information CIBC Wood Gundy #1000 – 1 Lombard Pl. Winnipeg, MB R3R 3N9 Canada Telephone: 204 946 9829 Deliver Instructions: FINS#: T079 CUID: WGDB FEDWIRE: DEALER #: 9280 ACCOUNT #: 711 079 77

DTC #: 5030 EUROCLEAR #: 9347 BK OF NYC/WGI ABA # 021000018 REP CODE: LQH

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