Coverdell Education Savings Trust Account
Do not file
with the Internal
(Rev. October 2016)
(Under section 530 of the Internal Revenue Code)
Department of the Treasury
Internal Revenue Service
Name of grantor
Check if amendment .
Name of designated beneficiary
Address of designated beneficiary
Date of birth of designated beneficiary
Name of responsible individual (generally the parent or guardian of the designated beneficiary)
Address of responsible individual
Name of trustee
Address or principal place of business of trustee
The grantor named above is establishing a Coverdell education savings trust account under section 530 for the benefit of the designated
beneficiary exclusively to pay for the qualified elementary, secondary, and higher education expenses, within the meaning of section 530(b)(2),
of such designated beneficiary.
The grantor has assigned the trust
) in cash.
The grantor and the trustee make the following agreement:
The trustee may accept additional cash contributions provided the designated beneficiary has not attained the age of 18 as of the date such
contributions are made. Contributions by an individual contributor may be made for the tax year of the designated beneficiary by the due date
of the beneficiary’s tax return for that year (excluding extensions). Total contributions that are not rollover contributions described in section
530(d)(5) are limited to $2,000 for the tax year. In the case of an individual contributor, the $2,000 limitation for any year is phased out between
modified adjusted gross income (AGI) of $95,000 and $110,000. For married individuals filing jointly, the phase-out occurs between modified
AGI of $190,000 and $220,000. Modified AGI is defined in section 530(c)(2).
No part of the trust account funds may be invested in life insurance contracts, nor may the assets of the trust account be commingled with
other property except in a common trust fund or a common investment fund (within the meaning of section 530(b)(1)(D)).
1. Any balance to the credit of the designated beneficiary on the date on which he or she attains age 30 shall be distributed to him or her
within 30 days of such date.
2. Any balance to the credit of the designated beneficiary shall be distributed within 30 days of his or her death unless the designated
death beneficiary is a family member of the designated beneficiary and is under the age of 30 on the date of death. In such case, that family
member shall become the designated beneficiary as of the date of death.
The grantor shall have the power to direct the trustee regarding the investment of the above-listed amount assigned to the trust (including
earnings thereon) in the investment choices offered by the trustee. The responsible individual, however, shall have the power to redirect the
trustee regarding the investment of such amounts, as well as the power to direct the trustee regarding the investment of all additional
contributions (including earnings thereon) to the trust. In the event that the responsible individual does not direct the trustee regarding the
investment of additional contributions (including earnings thereon), the initial investment direction of the grantor also will govern all additional
contributions made to the trust account until such time as the responsible individual otherwise directs the trustee. Unless otherwise provided
in this agreement, the responsible individual also shall have the power to direct the trustee regarding the administration, management, and
distribution of the account.
The “responsible individual” named by the grantor shall be a parent or guardian of the designated beneficiary. The trust shall have only one
responsible individual at any time. If the responsible individual becomes incapacitated or dies while the designated beneficiary is a minor
under state law, the successor responsible individual shall be the person named to succeed in that capacity by the preceding responsible
individual in a witnessed writing or, if no successor is so named, the successor responsible individual shall be the designated beneficiary’s
other parent or successor guardian. Unless otherwise directed by checking the option below, at the time that the designated beneficiary
attains the age of majority under state law, the designated beneficiary becomes the responsible individual. If a family member under the age
of majority under state law becomes the designated beneficiary by reason of being a named death beneficiary, the responsible individual shall
be such designated beneficiary’s parent or guardian.
Option (This provision is effective only if checked): The responsible individual shall continue to serve as the responsible individual for the
trust after the designated beneficiary attains the age of majority under state law and until such time as all assets have been distributed from
the trust and the trust terminates. If the responsible individual becomes incapacitated or dies after the designated beneficiary reaches the age
of majority under state law, the responsible individual shall be the designated beneficiary.
Cat. No. 25205V