1
Account Information
  • Program*
  • Telephone Number*
  • Account Owner or Custodian First Name*
  • Joint Account Owner First Name
  • Beneficiary First Name*
  • Account Number*
  • Email
  • Last Name*
  • Last Name
  • Last Name*
  • Social Security
  • Social Security
  • Social Security
2
Type of Distribution Request
  • If requesting an EFT or Check payment, this request will not be processed unless one of the distribution types are selected.
    See the Disclosure Statement for more information.
  • Qualified A qualified distribution is used to pay qualified higher education expenses for the beneficiary of the account . This generally includes tuition, fees, room and board, and the cost of books, school supplies and equipment required for enrollment or attendance of the beneficiary at an eligible educational institution. Earnings portion of the distribution is notsubject to federal income tax.
  • Non-Qualified Funds used for expenses other than Qualified Expenses are subject to the 10% IRS Non-Qualified Distribution Penalty on any earnings. In addition, the earnings portion of the distribution is includable in computing the federal taxable income for the distributee.
3
Distribution Details
  • Account Type(s)
  • CollegeSure Honors Savings Account #
  • 1-Year Fixed Rate CD Account #
  • 2-Year Fixed Rate CD Account #
  • 3-Year Fixed Rate CD Account #
  • InvestorSure CD** Account #:
  • CollegeSure CD Account #:
  • CD at Maturity
  • N/A
  • Yes
    No*
  • Yes
    No*
  • Yes
    No*
  • Yes
    No*
  • Yes
    No*
  • Distribution Amount
  • Entire Balance
    Other $ (complete section 5)
  • Entire Balance
    Other $ (complete section 5)
  • Entire Balance
    Other $ (complete section 5)
  • Entire Balance
    Other $ (complete section 5)
  • Entire Balance
    Other $ (complete section 5)
  • Entire Balance
    Other $ (complete section 5)
For requests made in November/December, specify for which calendar year you are requesting the distribution here
To avoid possible federal and/or state tax penalties, we recommend distributions be used in the same calendar year that expenses are paid.
* Distributions from your Account prior to the Maturity Date of the CD in which your Account is invested may result in Early Withdrawal Penalties as described in the Disclosure Statement.
** Distributions from your Account prior to the Maturity Date of an InvestorSure CD is permitted on the anniversary date only.
4
Distribution Method (Select a payment option.)
  • Check payment: Check(s) will be made payable to the Account Owner(s), Beneficiary or Educational Institution, and mailed to the address on file for the Account Owner(s). Checks will not be mailed directly to the school.
  • Electronic Funds Transfer (EFT) payment: Transfer funds to another Domestic (U.S.) institution payable to the following recipient. Note: An Electronic Funds Transfer can only be made to the Account Owner or Beneficiary on record.
5
Reinvestment Option
If you are not withdrawing the entire balance of this year’s maturing CD(s), specify below how you would like to reinvest the funds remaining in your Account. You will need to complete another Distribution Authorization Form each time additional funds are needed. A description of reinvestment options can be found in the program’s Disclosure Statement and/or product’s Terms and Conditions. Visit our website for more information (www.collegesavings.com or www.collegechoicecd.com). Reinvestments other than those identified as the default actions, could be considered part of your twice per calendar year investment change.
  • Account Type(s)
  • CollegeSure Honors Savings Account
  • 1-Year Fixed Rate CD*
  • 2-Year Fixed Rate CD*
  • 3-Year Fixed Rate CD*
  • Reinvestment Amount
  • Entire Balance
    Other $
  • Entire Balance
    Other $
  • Entire Balance
    Other $
  • Entire Balance
    Other $
*If you do not specify your reinvestment amount and your CD product(s) are at maturity, the default actions outlined in the Terms and Conditions and Disclosure Statement will apply.
6
Authorization (Required)
If the Account is an UGMA/UTMA, the Custodian should initial below and write “custodian” after his/her name.
If the source account is a Custodian (UGMA/UTMA) account, I certify that I am the custodian of the account and that the transfer is necessary for the welfare of the beneficiary. Furthermore, if the account is owned by a trust, organization or corporate entity, I certify that I am authorized to act on its behalf in making this transfer.
I certify that I have read and understand, consent and agree to all terms and conditions of the Disclosure Statement and understand the rules and regulations governing distributions from my 529 Bank Plan. I also certify that under penalty of perjury that all information contained herein is complete and correct, including the Taxpayer Identification Number or Social Security Number(s) set forth on this form. I understand that distributions from my Account prior to the Maturity Date of the CD in which my Account is invested may result in Early Withdrawal Penalties as described in the Disclosure Statement.
Online Banking Customers: Your verification is qualified by accessing our secure Online Banking portal. Please enter your Online Banking Access ID below.
  • Account Owner or Custodian Access ID
  • Joint Account Owner Access ID (if applicable)
  • Date
  • Date