Child Support Savings Initiative Program Withdrawal Form (Page 2 of 3) in pdf

Child Support Savings Initiative Program Withdrawal Form Page 2

3. Withdrawal Information

CSSI Learning Quest Account Number

Indicate the Type of Withdrawal and the Amount:

Nonqualified withdrawal*: $____________Dollar Amount

may only be paid to the beneficiary after the beneficiary reaches 25 years of age.

Qualified Withdrawal: $ __________ Dollar amount

Enclose copies of your receipts for your education expenses that you have paid. If

you have requested that the withdrawal be paid directly to an eligible educational

institution, please submit a copy of the bill from the institution. The amount of the

qualified withdrawal cannot exceed the amount stated on the receipts or bill.

4. Payment Method Instructions

(Choose one.)

By check to designated beneficiary.

Designated Beneficiary Mailing Address

City

State

ZIP

By check to eligible educational institution. (Provide the exact school

address below. Payments sent to the eligible educational institution are

reported under the designated beneficiary’s Social Security Number. If the

Student ID is not included, we will send the check to the beneficiary’s

address on record payable to the educational institution.)

Name of School (Complete only if the withdrawal is to be sent directly to the school.)

Department/Office/Contact Name

Child Support Savings Initiative Program Withdrawal Form Page 2