Stock Gift Donation Form

First Name *

Last Name *

Prefer to remain Anonymous.

Address *

City *

State/Province *

Zip *

Country

Email *

Approximate Stock Donation Value *

Donation Value

Date of Transfer *

// (mm/dd/yyyy)

Number of Shares *

Ticker Symbol *

Name of Security

What is the name of the firm/your broker? *

Firm's Phone Number

Any additional information

If you have any questions, or would like to inquire more information, please email Suzanne Khazaal at suzanne@iioc.com

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