THE XXX FOUNDATION, INC.

GRANT PAYMENT/STOCK TRANSFER SUMMARY

I.	GRANTEE INFORMATION

GRANTEE:	XXX

CONTACT PERSON: XXX

PHONE: XXX	FAX: XXX

ADDRESS:	XXX

TOTAL GRANT:	$XXX,XXX	PAID TO DATE:	$XXX,XXX

BALANCE DUE:	$XXX,XXX

PAYMENT SCHEDULED:	$XXX,XXX	DATE SCHEDULED:	XX/XX/XXXX

GRANTEE BROKER:	NAME

FIRM NAME

STREET

CITY,STATE,ZIP

Fax: XXX

GRANTEE ACCOUNT INFORMATION:	DTC XXX

ACCOUNT NAME:	GRANTEE

ACCOUNT NUMBER:	XXXX

II.	STOCK TRANSFER INFORMATION

CUSTODIAN:	NAME

BANK NAME

STREET

CITY,STATE,ZIP

Phone: XXX

Fax: XXX

INVESTMENT	NAME

MANAGERS:	INVESTMENT FIRM NAME

STREET

CITY,STATE,ZIP

Phone: XXX

Fax: XXX

Account Number: CUSTODIAN ACCOUNT NUMBER

NUMBER OF SHARES

STOCK NAME	TO BE TRANSFERRED

XXX	XXX