Your Information

Full Name (w/ M.I.)

Address

City

State
Choose AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
Zip Code

Daytime Phone

Your Broker Information

Broker's Name

Brokerage Firm

Brokerage Firm Address

City

State
Choose AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
Zip Code

Brokerage Account Number

United Way Broker/Stock Information

For brokerage firm name, Account number and DTC number, contact Colleen Kangas at Kangasc@unitedwaytwincities.org or 612-340-7610.

Name of stock

Number of shares

Brokerage Firm

Account Number

DTC Number