Appreciated Securities Notification Form

First Name

Please use between 1-20 characters. Please use only alphabet, apostrophe, hyphen, space and period.

Last Name

Please use between 1-20 characters. Please use only alphabet, apostrophe, hyphen, space and period.

Email Address

Country

Phone number

Please enter your area code, followed by your phone number, mobile phone preferred. Please use numbers only, no dashes or other separators.

Number of Shares

Symbol of Securities:

Designation of Gift

General Fund

Other (Specify Below)

Other Designation (If Applicable)

Stock will be transferred to Focus account at:

Charles Schwab

Merrill Lynch