Transfer of Securities Form

Families Moving Forward Electronic Transfer of Securities

Please print and complete this form and send one copy to your broker and one copy to Families Moving Forward to ensure the successful transfer and acknowledgement of your gift.

You can also download a Word version that you can complete electronically, then print and sign.

Donor Name(s): __________________________________________________________________

Address: ________________________________________________________________________

City: ___________________________________  State: __________  ZIP: ____________________

Phone:  _________________________________ E-mail: __________________________________

My/Our broker: ____________________________________ Firm: __________________________

My/Our Broker’s Phone: _____________ My/Our account number: __________________________

Please deliver ___________# of shares (or approximately $____________worth of shares) of

________________________________ from my/our above referenced account to Families Moving Forward’s account.

Families Moving Froward’s R.I. A.:    Merryfield Barnes, LLC

DTC 0443 Pershing
Families Moving Froward’s Growth Fund
Account #PU5-900094

Contact: 
Mark Bouton
607-882-9988
Mark.Bouton@merryfieldbarnes.com

____________________________________           ________________________________________
First Signature                                                    Second Signature (if joint account)

Date: ____________                                            Date: _______________

All gifts are tax deductible to the extent allowed by law.
Families Moving Froward’s is a 501(c)(3) not-for-profit organization . Tax ID #56-1633998

Families Moving Froward’s Contact:
Email: development
Telephone: 919-683-5878, ext. 31
Fax : 919-682-2509
Mailing address: Families Moving Forward’s, P.O. Box 25426, Durham, N.C. 27702