Dancing With Chicago Celebrities ELECTRONIC STOCK TRANSFER FORM

Thank you for your generation donation of stock.

Dancing With Chicago Celebrities does not receive any information that identifies you as the donor when your stock is transferred. Therefore, we kindly ask that you alert us in advance about the stock and number of shares you plan to donate. Please notify us of your gift by calling 630-699-6327 and leave a confidential voicemail or by completing this form.

IF YOU HAVE ANY QUESTIONS PLEASE CONTACT US AT info@amdwcc.org or call us at 630-699-6327

Forms or other required information can be sent to:

Dancing With Chicago Celebrities

Attn: Jane Melvin

116 West Illinois, Chicago, IL 60654

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* 1. Please provide the following donor information:

Contact Name

Company

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 2. Stock Issuer

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* 3. Number of Shares

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* 4. Estimated value of shares *

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* 5. If your donation is in support of an individual's fundraising efforts, please let us know whom we can thank:

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* 6. If your gift is in honor of or a tribute to someone, please list their name here:

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* 7. Area of support

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* 8. Would you like a copy of our IRS tax exempt letter for your records?

Yes

No thanks

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* 9. Would you like a copy of our W-9 form for your records?

Yes

No thanks

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* 1. Please provide the following donor information:

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* 2. Stock Issuer

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* 3. Number of Shares

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* 4. Estimated value of shares *

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* 5. If your donation is in support of an individual's fundraising efforts, please let us know whom we can thank:

Question Title

* 6. If your gift is in honor of or a tribute to someone, please list their name here:

Question Title

* 7. Area of support

Question Title

* 8. Would you like a copy of our IRS tax exempt letter for your records?

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* 9. Would you like a copy of our W-9 form for your records?

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* 10. Additional comments: