ࡱ> ?A>_  bjbj .*bb hhhhh||||T|+f   $Ch "   hh  hh ^@護*0+2,+^h^8          +              .: SAMPLE LETTER TO BROKER Date Broker Name Broker Address Broker City, State, Zip To Whom It May Concern: Please accept this letter as authorization to transfer stock as a charitable contribution to the charity shown below: Number of shares:Name of issuing company:(e.g., WellPoint, Inc.)Specific share lot description/cost basis:(i.e., indicate the original acquisition date and purchase price of the shares you wish to donate)Expected date of transfer of shares designated to charity:Brokerage account number or SSN:Mailing address (home or work):Daytime phone number:Name of charity receiving shares:Charity address:Charity phone number:Name of charitys stock broker:Charitys broker DTC#:Charitys brokerage account #:Donor(s):(e.g., your name) I authorize (Broker name) to transfer the securities or cash as listed above. I understand that upon receiving this form, (Broker name) will cancel any open orders that will affect the transfer. ( ) This contribution relates to my 2011-2012 WellPoint Associate Giving Campaign pledge. ( ) This contribution relates to my 2012-2013 WellPoint Associate Giving Campaign pledge. If you have any questions, please contact me at ___-___-____ or email WellPoints Associate Giving Campaign at HYPERLINK "mailto:AssociateGivingCampaign@wellpoint.com?subject=Stock%20Transfer"AssociateGivingCampaign@wellpoint.com. Sincerely, (Your Name) cc: The WellPoint Associate Giving Campaign Tiffany Etter, Program Manager, WellPoint Foundation 120 Monument Circle, Indianapolis, IN 46204 or Interoffice Mail: IN0103-A308 cc: Recipient Charity Name* Street Address City, State, Zip Code Contact Name/Title (if known) *Please forward an acknowledgement of this gift to me at the mailing address listed above. IMPORTANT NOTES: This form is provided as a sample template letter. You should consult with your attorney or tax advisor. Confirm with your brokerage firm whether this letter needs to be notarized. 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