WRT Securities Donation Form

WRT Securities Transfer

Your account will be credited with a donation equal to the value of the average (between the low and the high) price of the security on the date it was transferred to WRT. You will receive an acknowledgment of the transaction after we receive the securities.

VERY IMPORTANT: Please follow-up with your Broker to make the transfer. Your broker will receive a copy of this transaction requested via the email your provide. WRT is not permitted to pull the stock for transfer, and this can delay the process. If you have any questions, please contact Linda.Zarra@wrtemple.org.

The Fidelity DTC# is 0226
Westchester Reform Temple
Fidelity Acct # is Z-40036318

Congregant's Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Phone Number*

Area CodePhone Number

Email*

example@example.com

Broker's Name*

First NameLast Name

Company*

Broker's Phone Number*

Area CodePhone Number

Broker's Email*

example@example.com

Name of Stock*

Number of Shares*

CUSIP#/Ticker Symbol*

Westchester Reform Temple and Fidelity Investments cannot be responsible for any change in the value of the stock.

I/We authorize the delivery of the above mentioned shares from our account to Westchester Reform Temple.

Signature*

Please verify that you are human*