Security Gift Form - Uva Medical Alumni Association - Medical School

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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
st
th
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

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