American Red Cross

GIFT INSTRUCTIONS FORM

Please complete this gift form providing the information necessary to complete the transfer of a gift of stock to the Colonial Virginia Chapter of the American Red Cross (Tax ID#54-0505863) in accordance with the donor’s intent. At the time of gift transfer, please fax the completed form to:

Carolyn Latoski, CEO FAX: (757) 253-2396

DONOR’S NAME AND ADDRESS ( Please type or print)

____________________________________________________

SECURITIES GIFTED DATE OF TRANSFER:

Number of shares _____ Name of Security: _______________________________

Number of shares _____ Name of Security _________________________________

Specific American Red Cross Program to which gift should be directed, if any

_____ General Fund

_____ National Disaster Relief Fund

_____ International Response Fund

_____ Local Chapter: __________________________________________________

_____ Other: _________________________________________________________

e.g. specific disaster (Hurricanes, Tornadoes, Earthquakes, Red Cross

Museum, Biomed, etc.

TRANSFERRING BROKER

Name _____________________________________ Telephone ______________

Firm ______________________________________ City, State ______________