KMHD Contribution Of Securities
2015-04-07
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Date: ______________________
Authorization for Contribution of
Securities to KMHD
PLEASE FILL OUT, FAX OR MAIL A COPY TO YOUR BROKER
THEN FAX, MAIL OR EMAIL A COPY OF THIS FORM TO THE ADDRESS BELOW.
Donor Name: _______________________________________________________________________
Address: __________________________________________________________________________
City, State, Zip Code: _______________________________________________________________
Phone: ________________________ E-mail: ____________________________________________
TO:
Broker’s name: _______________________________________________________________
Brokerage firm: ________________________________________________________________
Address: ______________________________________________________________________
City, State, Zip Code: __________________________________________________________
Fax: _________________________________________________________________________
REGARDING:
Account Name: _______________________________________________________________
Account Number: _____________________________________________________________
INSTRUCTIONS:
I hereby authorize and instruct you to transfer the following securities:
Number of shares: ______________ Company Name: ___________________________
Via DTC from the above referenced account to:
KMHD / Oregon Public Broadcasting
c/o TD Ameritrade
DTC: 0188
Account #: 875302770
Julie Arnzen, Leadership Giving
KMHD / Oregon Public Broadcasting
503-977-7765, jarnzen@opb.org
7140 SW Macadam Ave., Portland OR 97219
OPB Tax ID: 93-0814638
CLIENT AUTHORIZATION:
___________________________________________
(Owner Name)
___________________________________________
(Owner Signature)
___________________________________________
(Joint Owner Name)
___________________________________________
(Joint Owner Signature)
..................................................................................................................................................................................................................................................
FOR KMHD USE ONLY: Member # ___________________ SRC: ____________________________ Allocation: ______________________________ 12-13
