HCAM Stock Donation Form

Name of person(s) donating*

Address*

City/State/Zip*

Phone*

Email*

Gift In Honor/In Memory (Select from drop down)

Select or enter value

Name of person being honored/remembered by gift

Please notify the following that a gift has been made in honor/memory.

(Name, Address, City, State, Zip)

Name and Number of Shares*

Special Instructions:

HealthCare Access Maryland gratefully accepts gifts of stock. Your contribution supports our mission to connect Maryland residents to health insurance and care. Donating stock is simple – please follow these steps:

1. Initiate a gift transfer through your broker using HealthCare Access Maryland’s DTC number. For reporting and tracking purposes, please have the initiating firm include the donor’s name on the Memo line.

2. Notify HealthCare Access Maryland by completing and submitting this Gift of Stock form.

If you have any questions about giving options to support HealthCare Access Maryland, please contact:

Caitlin Mulrine, Director of Development & Major Giving

(cmulrine@hcamaryland.org)

DTC number: 0226

Fidelity account number: Z40336495

Tax Identification Number: 52-2017095

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