Please complete and sign this gift form providing the information necessary to complete the transfer
of a gift of stock to the Cerebral Palsy Research Foundation of Kansas, Inc. (Tax ID #23-7314938) in
accordance with the donor's intent. This form may also be used to instruct the donor's broker to
electronically transfer a gift of stock. At the time of gift transfer, please fax the completed form to:
CPRF
Development Division
FAX: (316)652-1526

Donor's Name and Address (please type or print)
____________________________________
____________________________________
____________________________________

PaineWebber
121 S. Whittier St.
Wichita, KS 67207

Cerebral Palsy Research Foundation of Kansas, Inc.
Account Number:
#WT0539908

_____ Donor wishes to remain anonymous

Securities Gifted
Date of Transfer__________
Number of Shares_____________
Name of Security_________________
Number of Shares_______________
Name of Security____________________________________

Specific CPRF Program to Which Gift Should Be Directed, if any
______ General Support Fund
______ Technical Services Division
______ Employment Services
______ Community Services
______ Permanent Endowment

Transferring Broker Name__________________________ Telephone______________
Firm___________________________ City, State_____________