Gifts of Publicly Traded Securities and Mutual Funds
This form is to be completed by the donor and authorizes your broker to complete the transfer of securities to
PALLIACCO. Please note, you will receive a tax receipt for the fair market value of your gift, which is the selling
price of the securities on the date the gift is sold by Desjardins Securities. It is PALLIACCO's policy to sell any
donated securities at the first opportunity, generally within 24 hours of receipt of the securities. You are also
advised to consult with a qualified professional financial planner before making this type of gift.
Name of donor: _____________________________________________________________________
Address: __________________________________________________________________________
City: ________________________________
Telephone: __________________
Province: _____________
Fax: _______________
Postal Code: ____________
Email: _______________________
Name of donor's broker & firm: _______________________________________________________
Broker's Telephone: _____________
Fax: ________________
Email: _______________________
Name of securities to be donated: ______________________________________________________
Number of shares or units to be donated: ________________________________________________
Description of securities (e.g. CUSIP, common shares, preferred shares, Exchange, symbol, etc.):
Please ask your broker to contact STÉPHANE LAVOIE at DESJARDINS SECURITIES to verify the transfer of
securities.
Receiving Institution:
DESJARDINS SECURITIES, LAVAL QC
Investment Services Associate:
CUID # VMDM, DTC 5028, Dealer/Rep Code 9356 L1XR
STÉPHANE LAVOIE, stephane.lavoie@vmd.desjardins.com
Telephone:
Fax:
1-800-449-7881 or 1-450-682-6101
1-450-682-6474
PALLIACCO account number: 7K-GCMA-0
Signature of donor: ________________________
Date: _________________
Please mail, or scan and email, this form to CAROLE C. MARTINEAU at PALLIACCO:
PALLIACCO
2280 rue Labelle, Mont-Tremblant, QC J8E 1T8
Phone: 819-717-9646
Toll free: 855-717-9646
E-mail: admin@palliacco.org
Thank you for your support!