Charitable Gift Form: Securities Donation

Name & Type of Securities:*

(e.g.: DELL common stock)

Security Symbol:*

Number of Shares:*

Transfer Date:*

Donor Name:*

(Individual, Corporation, Foundation)

Donor Address:*

Street Address City State / Province / Region ZIP / Postal Code

Donor Telephone Number:

(to be used only if a question/problem arises in the donation process)

Donor wishes to receive acknowledgement via email:*

Donor Email:*

Broker Name:*

Broker Company:*

Broker Contact / Telephone Number:

Justice Policy Institute is a registered 501(c)3 organization and all contributions are tax deductible as permitted by law.