Stock Transfer Notification Form

Thank you for completing this notification form to let Horizon 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 *

Email Address *

Gift Information

What would you like your gift to impact?

Greatest need (Transportation, Food Insecurity, Medical, Dental, and Behavioral Health Care)

Rooted in Rural Endowment

Specific Clinic Fund

Option 3

Option 4

Option 5

Gift Type:

Stock

Mutual Fund

Charity's Information

Charity's Legal Name: *

Charity's Tax ID: *

Charity's Address: *

Charity's Email Address: *

Charity's Phone Number: *

Charity's Broker Institution: *

Charity's Broker Institution Address: *

Charity's Account Name: *

Charity Brokerage Account Number: *

Charity'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.

First Name

Last Name

Comments

Thank You

Thank you for your interest in supporting Horizon Health Foundation.

One of our gift planning representatives will contact you to discuss your charitable plans.

Support healthcare in your community

Stock Transfer Notification Form

Personal Information

Gift Information

Charity's Information

Thank You

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