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Gift Form
This form provides the information necessary to complete the
transfer of a gift of stock to EMQ Children & Family Services
(Tax ID# 94-1254641) in accordance with the donor's intent. Please
complete and sign this gift form. This form may also be used to
instruct the donor's broker to electronically transfer a gift
of stock. At the time of gift transfer, please fax the completed
form to:
HOLLYGROVE
Attn: Scott Staub
FAX: (408) 364-4034
EMQ Broker Information:
Charles Schwab
DTC Number: 0164
EMQ Children & Family Services
Account Number: 3026-2852
Charles Schwab
Donor Information:
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Name:
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____________________________________
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Address:
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____________________________________
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City, State Zip:
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____________________________________
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Donor wishes to remain anonymous ___
Securities Gifted:
Date of Transfer: _________________________
Name of Security: _________________________
Number of Shares: _________________________
Name of Security: _________________________
Number of Shares: _________________________
Transferring Broker Information:
Broker Name: _________________________
Phone Number: _________________________
Brokerage Firm: _________________________
Address: City, State Zip: _________________________
donor's signature ____________________________________ date_________________________
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