Donate Stock | Stock Gift Intake Form

Elevate your impact even further with a tax-smart gift of stock to Bloodworks Northwest.

To start the process, please complete the form below.
E: [email protected] T: 206-568-3614

Account Name: Bloodworks Stock Gifts
Account Number: 052-66360-6

Bloodworks Northwest Tax ID:
[EIN] #91-1019655

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Email(Required)

Additional Information or Notes

Brokerage Firm(Required)

Broker Name(Required)

Broker Phone Number(Required)

Number of Shares(Required)

US Stock Ticker Symbols(Required)

By signing below, I confirm that:(Required)

I am the legal owner of the shares described above and have the authority to donate them.

The shares are not “restricted securities” under Rule 144.

The shares have been held for more than one year and were not acquired from the issuer or an affiliate privately.

The shares are freely tradeable and not restricted under law or contract.

I am not an affiliate of the company and posses no material nonpublic information

I understand Bloodwork's policy is to sell donated securities as soon as possible after receipt.

Signature(Required)

Date(Required)