Stock Transfer Intention Form

Stock Transfer Form

It's simple to make a gift of stock to Main Line Health!

We will receive basic information about your intentions so we can assist and credit your gift when it arrives.

Steps:

Fill out this form and we will contact you.
Contact your broker to initiate the transfer.

Notes:

Our office can help you with gift designations.
We do not ask for your account number online for security.

Bolded items with an asterisk (*) are required fields.

Organization

Select Organization*

Donor Information

Name*

Address 1*

Address 2

City*

State*

Postal Code

Country

E-Mail*

Home Phone*

Broker/Stock Information

Brokerage/Financial Institution Name*

Broker/Contact Name*

Broker/Contact Phone*

Broker/Contact E-mail

Broker/Contact Fax

Anticipated Transfer Date*

Stock Name*

Number of Shares*

Special Instructions to Broker

Gift Designation Information

My gift is available for the unrestricted use of the entity indicated above.

I would like to designate my gift for a specific use. (Please email Caitlyn Walters at waltersc@mlhs.org with your designation.)

Main Line Health Foundations tax IDs

Main Line Health: Tax ID 23-2331531
Lankenau Medical Center Foundation: Tax ID 23-2176723
Lankenau Institute for Medical Research: Tax ID 23-2175659
Bryn Mawr Hospital Foundation: Tax ID 23-2179020
Bryn Mawr Rehab Hospital Foundation: Tax ID 23-2507348
Paoli Hospital Foundation: Tax ID 23-2359407
The Riddle HealthCare Foundation: Tax ID 04-3601189
Main Line Health HomeCare and Hospice: Tax ID 23-2308028
Mirmont Treatment Center: Tax ID 23-2215243

Main Line Health

Main Line Health

Bryn Mawr

Bryn Mawr Rehab

Lankenau

Paoli

Riddle

Stock Transfer Intention Form

Organization

Donor Information

Broker/Stock Information

Special Instructions to Broker

Gift Designation Information

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Will or Trust

Appreciated Securities

Life Insurance

Retirement Plan

Real Estate

Donor-Advised Fund

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Main Line Health Foundations tax IDs