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Headquarters: Canadian Mental Health Association, British Columbia Division, Suite 905 - 1130 West Pender Street, Vancouver, BC V6E 4A4

Phone: 604-688-3234

Date

MM slash DD slash YYYY

Donor's Name

First Last

Donor's Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Donor's Email

Name of Donor's Broker

First Last

Broker's Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Instructions to Donor's Broker:

This is your authorization to transfer shares from my account to the account of Canadian Mental Health Association (National) held at Scotiatrust.

Please deliver these securities to Scotiabank at the address noted below, for deposit to the account of Canadian Mental Health Association.

Donor's Account Number

Name of the Security to be Transferred

Number of Shares to be Transferred

Transfer to: Canadian Mental Health Association

Account Number: 7803321814

FINS# T525 DTC# 4816

CUID# BNSC Intermediary Code BSNG

Contact: Scotia Asset Management LLC

Attn: Ryan Mullins MBA, CFA

Portfolio Manager

40 King St. W, 38th Floor

Toronto ON M5H 3Y2

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