Securities Form

Securities Donation Form

Charitable donation of publicly traded securities in kind
Legal Name of donor(s), as should appear on receipt*

First NameLast Name
Donor Mailing Address (required for receipt)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Donor Phone Number
Please enter a valid phone number.
Donor Email*
example@example.com
Delivering Institution*
Broker Contact Name*

First NameLast Name
Broker Contact Phone Number
Please enter a valid phone number.
Broker Contact Email *
A copy of this form will be sent to your broker at the email provided to initiate this transaction.
Delivering Institution Name*
Donor Account Number*
Securities Description
Securities Symbol/CUSIP
Quantity
Approximate Value*
Additional comments/instructions/information
Transfer Securities in Kind To

Receiving Institution Name: RBC PH&N Investment Counsel
Account Name: Ronald McDonald House Alberta
Account Number: 46308834-13
CUID: DOMA
DTC: 5002
Contact Name: Alexia Golden
Contact Phone Number: 403-515-6837
Contact Email: alexia.golden@rbc.com
Recognition name
Please indicate if you would prefer a name other than your legal name used for any recognition purposes.
I prefer that my gift remain anonymous and my name will not be printed on recognition materials.
A charitable tax receipt from Ronald McDonald House Alberta will be based on the closing price of the securities on the day the securities are received in Ronald McDonald House Alberta's brokerage account. In order to receive a charitable tax receipt for the calendar year, the securities must be transferred to the Ronald McDonald House Alberta account no later than December 15, of the same calendar year. These securities have been transferred to the Ronald McDonald House Alberta account without restriction.

I have read and understand the above information and authorize the transfer of the above mentioned assets to Ronald McDonald House Alberta. I also agree that Ronald McDonald House Alberta, or its agent, may contact my broker for the purpose of concluding this transaction.
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Securities Donation Form