Security Gift Form - Uva Medical Alumni Association - Medical School printable pdf download

Security Gift Form - Uva Medical Alumni Association - Medical School

SECURITY GIFT FORM

NOTICE OF INTENT (please forward to our office and your broker)

Donor’s name:

______________________________________________

Donor’s address:

______________________________________________

Donor’s telephone number______________ E-mail _________________________

Security(ies) and Number of shares: ______________________________________

Expected date of transfer:

______________________________________

Transfer type: ____electronic (DTC) OR ____ mutual fund transfer

OR ___stock certificate & stock power (

)

when donor or broker holds certificates

Gift Designation: ___________________________________________________

(eg. Class Fund, Endowment, Annual Giving (unrestricted), Dues or other named fund)

Transferring broker firm name & contact person:___________________________

Broker’s address: ____________________________________________________

ELECTRONIC TRANSFER INFORMATION (for donor’s broker)

Clearing broker:

Pershing & Company

DTC Number: 443

Account Number

N7M-001327 (formerly 58L-001144)

Account Name:

University of Virginia Gift Account

Reference:

[donor’s name]

NON-ELECTRONIC TRANSFER INFORMATION

A. Stock Certificates held by the donor or donor’s broker.

Please forward the following to our office, Attention: Director of Accounting

For security reasons, please mail separately. (The signed stock power form and

certificate together are negotiable). Please include Notice of Intent information.

1. Unsigned certificates or bonds.

2. Stock power form signed by the individual named on the stock certificate and their

signature medallion-guaranteed by a bank or broker.

Do not complete any other information on the form.

B. Mutual Fund gifts

(contact our office if special assistance is required)

Contact your mutual fund directly for specific instructions and allow extra time for

processing (often 3-5 weeks and could be longer in December).

TIMING OF GIFTS –

gifts must be transferred (post-marked, if mailed, or delivered, if sent by

carrier) no later than December 31

for calendar year-end gifts or June 30

for fiscal year-end gifts.

Revised Nov. 2012 security gift instructions

Security Gift Form - Uva Medical Alumni Association - Medical School

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