Donation Form

Manna Food Bank of Bracebridge, Inc.

Please transfer the following position:

Description: ______________________________

Quantity: ________________________________

Symbol: _________________________________

Exchange: _______________________________

CUSIP (if available) ________________________

Delivering Institution Information:

Delivering Institution Name: __________________

Account Name: ____________________________

Account Address: __________________________

Account #: ________________________________

CUID: ____________________________________

FINS/DTC: ________________________________

Contact Name: _____________________________

Phone #: __________________________________

Receiving Institution Information

Receiving Institution Name:  RBC Dominion Securities

Account Name:  Manna Food Bank of Bracebridge, Inc.

Account Address:  RBC Bracebridge

Account #: 546      CUID:  DOMA        FINS/DTC:  5002

Contact Name:  Connor Ryan/Lynne Chynoweth - Phone:  (705) 645-2695

Additional Information/Instructions:

Donor Name: ___________________________  Same as above __________

Donor Address: ___________________________ Same as above _________

Contributing Client Authorization:

Client Signature _________________________   Date:  ________________