Securities Donation Form

Ukrainian Canadian Congress Charitable and Educational Trust
hereby pledge to donate to the Ukrainian Canadian Congress Charitable and Education Trust the following share certificates by way of transfer to an account held by the UCC C & E Trust
The account information to facilitate the transfer of the above shares is as follows: RBC Dominion Securities Ukrainian Canadian Congress Charitable & Educational Trust. Account number: 804-20124-12 Phone number: 604-257-2504 Postal Address: 745 Thurlow St, 20th Floor, Vancouver, BC V6E 0C5 An income tax receipt for your donation will be provided upon confirmation of receiving the share transfer and the amount will be determined at the date of receiving the transfer. Please provide the following information in order to process the income tax receipt and forward this form to ucc@ucc.ca
Name(Required)
Address(Required)
MM slash DD slash YYYY