Stock Transfer Intention Form

It's simple to make a gift of stock to Essentia Health Foundation!

We will receive basic information about your intentions, so we can lend any assistance and credit your gift when it arrives.

Steps:

Fill this form out and we will contact you.
Make sure you contact your broker to initiate the actual transfer.

Notes:

Our office can help you walk through the possibilities for gift designations.
For security reasons, we do not ask for your account number over the Internet.

Bolded items with an asterisk (*) are required fields.

Donor Information

Name*

Address 1*

Address 2

City*

State*

Postal Code

Country

E-Mail*

Home Phone*

Broker/Stock Information

Brokerage/Financial Institution Name*

Broker/Contact Name*

Broker/Contact Phone*

Broker/Contact E-mail

Broker/Contact Fax

Anticipated Transfer Date*

Stock Name*

Number of Shares*

Special Instructions to Broker

Gift Designation Information

My gift is available for the unrestricted use of Essentia Health Foundation.

I would like to designate my gift for a specific use.

The gift planning information presented on this site is intended as general. It is not to be considered tax, legal, or financial advice. Please consult your own personal advisors prior to any decision.

Stock Transfer Intention Form

Donor Information

Broker/Stock Information

Special Instructions to Broker

Gift Designation Information

FOR YOU

RESOURCES