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 email@example.com 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 OK Question Title * 1. Please provide the following donor information: Contact Name Company Address Address 2 City/Town State/Province -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP/Postal Code Email Address Phone Number OK Question Title * 2. Stock Issuer OK Question Title * 3. Number of Shares OK Question Title * 4. Estimated value of shares * OK Question Title * 5. If your donation is in support of an individual's fundraising efforts, please let us know whom we can thank: OK Question Title * 6. If your gift is in honor of or a tribute to someone, please list their name here: OK Question Title * 7. Area of support Unrestricted Underwriting - Event Underwriting - Administration (Software) Underwriting - Administration (Other) Other (please specify) OK Question Title * 8. Would you like a copy of our IRS tax exempt letter for your records? Yes No thanks OK Question Title * 9. Would you like a copy of our W-9 form for your records? Yes No thanks OK Question Title * 10. Additional comments: OK CLICK HERE TO SUBMIT. THANK YOU!!!