Certificate Transfer
Notification of Transfer
Richard Hugo House
Attention: Development
Fax: (206) 320-8767
I (We) are donating ________shares of _________________________________ common stock to be used as follows:
General operating: ________
Restricted program: ___________
My (our) broker is ____________________________________________________
Donor information:
Name(s): _____________________________________________________________
Address: ____________________________________________________________
City: ______________________________
State: _____________________________ Zip: _______________
Telephone: _______________________________
Fax:_____________________________________
E-Mail:__________________________________
Date: ___________________________________
____ I wish to remain anonymous
____ I want my entire gift to be tax deductible; please send no premiums
____ I am making a gift ____In honor _____ In memory of ____________________
