Huntington Medical Research Institutes (HMRI) - Development Dept.
Securities Transfer Request Form To make a gift of stock shares, please use this form to transfer the shares from your brokerage account to HMRI’s account. 1) Complete the form below and send a copy to your broker. 2) Please also fax a copy of this form to Dan Maljanian at (626) 397-5808 or email:
[email protected] For questions: call (626) 397-5804. Mailing address: 734 Fairmount Ave., Pasadena, CA 91105-3104. Date: To: Broker Name Brokerage Firm Broker Phone Number Please accept this letter as your authorization to deliver free: Name of Stock Number of Shares which you hold in my / our account in the: Name of: Account Number: Please transfer to the account of HMRI through DTC as follows: Charles Schwab & Company DTC # Clearing 0164, Code 40 For the account of Huntington Medical Research Institutes (HMRI) Account #: 9044-4718 Broker Name: Christopher Quiroz, Financial Consultant Phone Number: (626) 304-3803 (Pasadena, CA) Fax Number: (626) 304-3813 Address: 800 East Colorado Blvd., Suite 170, Pasadena, CA 91101 Signature(s) of account owners(s):
Please restrict my gift to: D Where the Need is Greatest
D Other: