Gift of Securities Transfer Notification

The purpose of this form is to notify The Julian Center of an anticipated transfer of securities. To transfer the securities, you must contact your broker. Since current Federal privacy statutes prevent your broker from providing us with any personal information, including your name, this form will allow you to share that information with us so we may connect you with your gift receipt at the completion of the transaction.

Your broker may need the following information to complete the transfer:

Bank: Key Investments

Account Name: The Julian Center, Inc.

Account Number: HR3-034553

DTC Number: 0443

Please complete and mail or email this form to The Julian Center:

Gift of Securities Transfer Notification Form

If you are human, leave this field blank.

First Name *

Last Name *

Address *

Address

City

State/Province

Zip/Postal

Country

Phone Number *

Broker Information

Broker Firm *

Broker Name *

Broker Phone Number *

Transfer of Securities Information

Anticipated Date of Transfer *

Description of securities being transferred (i.e. name of security, number of shares, approximate dollar value): *