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By Check

Please print out this page. Fill in the appropriate blanks and mail to:

Blacksmith Institute
2014 Fifth Avenue
New York, NY 10035

or Fax to our office: (212) 647-8334

Enclosed is my gift of:


$50 __________

$100 __________

$250 __________
$500 __________ $1000 __________ Other $_________
Total
donation
 
 
Name  
Street
Address
 
City  
State  
ZipCode  
Telephone  
E-mail  


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Stocks / Securities

Please fill in the appropriate blanks and give this form to your broker, or contact Corinne Ahearn at (212) 870-3490 or info@blacksmithinstitute.org.

Please ask your broker to fax a copy of this form to Corinne Ahearn at (212) 647-8334. In order for Blacksmith Institute to confirm the receipt of your stock gift, please include on the instructions your name, address, telephone number, and e-mail address.

Brokerage Firm: ________________________________
Broker: ________________________________
Address: ________________________________
  ________________________________
Account #: ________________________________
Account Title: ________________________________


Dear Broker:
Please accept this letter as authorization to gift:

_________ shares of _____________________ stock to:

Blacksmith Institute, a 501(c)(3) public charity
DTC number: 5198
Account number: 85702093

Thank you for your immediate attention to this matter.

Sincerely,

____________________________
Signature of gifting share holder (donor)
_______________________
Date


Please provide charity's broker with contact information for acknowledgement
Donor name: ___________________________
Address: ___________________________
  ___________________________
Phone: ___________________________
Email: ___________________________

*All contributions are tax-deductible as allowable by law. Blacksmith Institute is a registered 501 (c) 3 and a recognition letter/receipt will be sent following all contributions.

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