Fillable Brokerage Account Application, Coverdell Esa Forms (Page 4 of 4) in pdf

COVERDELL ESA

(Education Savings Account)

Amendment -

check to update an existing ESA

Designated Beneficiary

Name

Home Phone

First

Middle

Last

Home Address

Social Security / Tax ID Number

Street

Date of Birth

City

State

ZIP

Responsible Individual

Name

Home Phone

First

Middle

Last

Home Address

Social Security / Tax ID Number

Street

Relationship to Beneficiary

City

State

ZIP

The Responsible Individual may change the Designated Beneficiary to another member of that Beneficiary’s family

Yes

(per Section 529(e)(2) of the Internal Revenue Code).

Yes

The Responsible Individual shall continue to serve as such for this custodial account after the Designated Beneficiary attains the age of majority

under applicable state law, until all assets have been distributed and this account terminates. If the Responsible Individual becomes incapacitated

or dies after the Designated Beneficiary reaches the age of majority, the Responsible Individual shall be the Designated Beneficiary.

If selections are not made, the default will be “No."

Depositor

Same as the Responsible

Name

First

Middle

Last

Individual?

Yes*

*This section may be left blank.

Social Security / Tax ID Number

Home Address

Street

Home Phone

Deposit Amount

City

State

ZIP

Successor Responsible Individual

(optional)

In the event of the death or legal incapacity of the Responsible Individual while the Designated Beneficiary is a minor under state law, the following person is

designated the Responsible Individual

(if no successor is named, the Successor Responsible Individual shall be the Designated Beneficiary’s parent or guardian).

Name

Home Phone

First

Middle

Last

Home Address

Social Security / Tax ID Number

Street

Relationship to Beneficiary

City

State

ZIP

Death Beneficiary

(optional)

The person named below is the primary death beneficiary of 100% of this ESA

(to name additional beneficiaries, submit a separate Designation of Beneficiary form). If a

death beneficiary is not designated or if all primary and contingent death beneficiaries predecease the designation beneficiary, the designated beneficiary's estate will be the

death beneficiary.”

Name

Social Security / Tax ID Number

First

Middle

Last

Home Address

Date of Birth

Street

Relationship to Beneficiary

City

State

ZIP

Share %

Signatures

Responsible Individual - By signing below, I affirm that I have received a copy of the Application, 5305-EA Plan Agreement and Disclosure Statement. I understand

that the terms and conditions which apply to this Coverdell ESA are contained in this Application and the Plan Agreement, and I agree to be bound by those terms

and conditions and all applicable laws. I assume complete responsibility for certifying that I am qualified to assume the responsibilities of the Responsible Individual

as set forth in the Plan Agreement, and for managing this account and authorizing transactions involving contributions (including rollover contributions) and distributions.

Depositor - By signing below, I affirm that I have received a copy of the Application, 5305-EA Plan Agreement and Disclosure Statement. I understand that the terms

and conditions which apply to this Coverdell ESA are contained in this Application and the Plan Agreement, and I agree to be bound by those terms and conditions

and all applicable laws. Further, I affirm that I understand the eligibility requirements for the Coverdell ESA deposit I am making, and that I qualify to make the

deposit. I assume complete responsibility for determining my eligibility each year I make a contribution, and ensuring that all contributions are within the limits set by

tax laws.

*SF2363*

Responsible Individual Signature

Date

Depositor Signature

Date

(if different from Responsible Individual)

SF2363/9-15

Page 4 of 4