Securities Transfer Form Date: _______________________________________________________________________________ Donor Information Name of Donor: ______________________________________________________________________ Name of Stock: _________________________________Number of Shares: ______________________ Name of Broker: ________________________________Phone: _______________________________ Account Number: _____________________________________________________________________ ____Annual Fund
_____Other (specify): ________________________________________________
Date of Transfer: _____________________________________________________________________ Value of Stock:
High: _________________
Instruction to Donor: 1) Transfer stock using GHCDS broker: Peter Rohr Merrill Lynch, Pierce, Fenner & Smith, Inc. 1650 market Street Philadelphia, PA 19103 215-587-4731 800-263-4519 DTC # 5198 Account #: 871-07F08 EIN#: 66-0566743 2) Please email a copy of this form to: Linda Stamper- Keularts Director of Advancement 340-778-1974 ext. 2113
[email protected]
Low: _________________ Mean: ________________