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5314 / 2506E (Rev. 7/2013) ©2013 Ascensus, Inc.
PART 1. DESIGNATED BENEFICIARY
Name (First/MI/Last) __________________________________________
Social Security Number ________________________________________
Date of Birth ____________________ Phone ______________________
Account Number__________________________________ Suffix______
Responsible Individual Name ___________________________________
PART 2. COVERDELL ESA TRUSTEE OR CUSTODIAN
To be completed by the Coverdell ESA trustee or custodian
Name ______________________________________________________
Address Line 1 _______________________________________________
Address Line 2 _______________________________________________
City/State/ZIP________________________________________________
Phone________________________ Organization Number ___________
PART 5. WITHDRAWAL INSTRUCTIONS
ASSET HANDLING
(Assets identified below will be liquidated immediately unless otherwise specified in the Special Instructions section.)
Asset Description Amount to be Withdrawn Special Instructions
__________________________________________ ______________________ _____________________________________________________________________
__________________________________________ ______________________ _____________________________________________________________________
__________________________________________ ______________________ _____________________________________________________________________
PAYMENT METHOD
Cash
Check (If the withdrawal reason is transfer to another Coverdell ESA, the check must be made payable to the receiving organization.)
Make payable to __________________________________________________________________________________________________________
Internal Account
Account Number _____________________________________________ Type (e.g., checking, savings, Coverdell ESA)________________________
External Account (e.g., EFT, ACH, wire) (Additional documentation may be required and fees may apply.)
Name of Organization Receiving the Assets ___________________________________________ Routing Number (Optional) __________________
Account Number _____________________________________________ Type (e.g., checking, savings, Coverdell ESA)________________________
WITHDRAWAL AUTHORIZATION
This form is to be completed by the Coverdell ESA responsible individual or death beneficiary.
Refer to page 2 for reporting information.
COVERDELL
ESA
PART 3. DEATH BENEFICIARY INFORMATION
This section should only be completed by a death beneficiary taking a withdrawal due to the death of the original designated beneficiary.
Name (First/MI/Last) __________________________________________ Address Line 1 ________________________________________________
Tax ID (SSN/TIN) ______________________________________________ Address Line 2 _______________________________________________
Date of Birth ____________________ Phone ______________________ City/State/ZIP ________________________________________________
PART 4. WITHDRAWAL INFORMATION
Total Withdrawal Amount ___________________________ Withdrawal Date ________________ This Withdrawal Will Close This Coverdell ESA
The total withdrawal amount consists of the following. Basis $____________________________ Earnings $________________________________
PART 6. SIGNATURES
I certify that I am the proper party to authorize payments from this Coverdell ESA and that all information provided by me is true and accurate. All
decisions regarding this withdrawal are my own, and I expressly assume responsibility for any consequences that may arise from this withdrawal.
I agree that the trustee or custodian is not responsible for any consequences that may arise from processing this withdrawal authorization.
X
_________________________________________________________________________________________________ _______________________________________
Signature of Responsible Individual or Death Beneficiary Date (mm/dd/yyyy)
X
_________________________________________________________________________________________________ _______________________________________
Notary Public/Signature Guarantee (If required by the trustee or custodian) Date (mm/dd/yyyy)
X
_________________________________________________________________________________________________ _______________________________________
Authorized Signature of Trustee or Custodian Date (mm/dd/yyyy)
WITHDRAWAL REASON (Select one)
1. Transfer to Another Coverdell ESA
The designated beneficiary of the account receiving these assets
is not the current designated beneficiary.
2. Normal Withdrawal
3. Disability
4. Death Withdrawal by a Death Beneficiary
5. Prohibited Transaction
6. Excess Contribution Removed Before the Excess Removal Deadline
(Enter the net income attributable to the excess and select a or b)
Net Income Attributable _________________________________
a. Excess Contributed and Removed in the Same Year
b.
Excess Contributed in One Year and Removed in the Next Year
