Stock Transfer Notification Form

Thank you for completing this notification form to let Scripps Health 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?

Scripps Health Greatest Need

Scripps Clinic Greatest Need

Scripps Memorial Hospital Encinitas

Scripps Memorial Hospital La Jolla

Scripps Green Hospital

Scripps Mercy Hospital, San Diego/Chula Vista

Gift Type:

Publicly Traded Stock

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): *

Include a signed stock power form for each certificate. You may obtain this form from your brokerage or bank.

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 Scripps Health.