Coverdell ESA Withdrawal Authorization Form

LEGG MASON FAMILY OF FUNDS
Coverdell ESA Withdrawal Authorization Form
Use this form to request a distribution from your Legg Mason Funds Coverdell Education Savings Account. For assistance in
completing this form, please call Shareholder Services at 1-800-822-5544 Monday through Friday, 8:00 am - 5:30 pm ET.
An annual, per account Custodian fee will be deducted from your distribution for each account that is fully liquidated. The fee is
charged whether the funds are distributed to you or transferred to a successor custodian or trustee. This fee is not prorated for
periods of less than one full year.
1
ACCOUNT INFORMATION
… Please check here if the address provided is your new address of record
(A Medallion Signature Guarantee is required in Section 6)
Designated Beneficiary (first)
(middle initial)
(last)
Account Number
Date of Birth
Phone Number
Street Address
City, State & Zip Code
2
DISTRIBUTION REASON (CHECK ONE)
Distributions Used for Qualified Education Expenses:
…
Distributions from this account are being used for qualified education expenses of the Designated Beneficiary.
Distributions Not Used for Education Expenses:
…
Distribution is not being used for qualified education expenses and none of the other reasons below apply.
…
Permanent Disability of the Designated Beneficiary (within the meaning of section 72(m)(7) of the Internal Revenue Code).
…
Death. Designated Beneficiary is deceased. Please attach a certified copy of death certificate and a Coverdell ESA Application for Designated Death
Beneficiary account. If rolling over to a Coverdell ESA for the Designated Death Beneficiary, complete either the transfer or rollover option below.
Designated Death Beneficiary or Estate Name
Social Security or Tax ID
Date of Birth
Relationship to deceased
…
Removal of Excess Contribution plus earnings before deadline. Tax year in which the contribution made:
Is the contribution plus earnings being removed in the same year? … Yes … No
…
Transfer, including transfer due to Divorce or Legal Separation. Payable to:
Medallion Signature Guarantee required.
Please complete Section 6
…
Rollover or transfer to another Coverdell ESA for the following family member:
…
Beneficiary/Student has attained Age 30.
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Medallion Signature Guarantee required.
Please complete Section 6
Coverdell ESA Distribution Request Form 1
3
DISTRIBUTION INSTRUCTIONS
Indicate the amount and payment method for the requested distribution.
A. Distribution Amount
…
One-time partial withdrawal. …
Total Liquidation.
Fund Name and Share Class/NASDAQ Symbol (if available)
$ Gross Amount or Number of Shares
Fund Name and Share Class/NASDAQ Symbol (if available)
$ Gross Amount or Number of Shares
Fund Name and Share Class/NASDAQ Symbol (if available)
$ Gross Amount or Number of Shares
B. Payment Instructions
Unless indicated otherwise below, the distribution requested on this form will be paid by check, and made payable to the
responsible individual for the benefit of the designated beneficiary and sent to the address of record, unless the designated
beneficiary has become the responsible individual and has submitted the appropriate paperwork to do so.
…
Distribute by check made payable to the alternate payee indicated below and/or send to the alternate address detailed below.
A Medallion Signature Guarantee in Section 6 is required if this option is selected.
Alternate Payee (if applicable)
Alternate Street Address (if applicable)
City, State & Zip Code
Account Number (if available)
Account Registration [Account Owner’s Name(s)]
Fund Name and Share Class
Percentage
Fund Name and Share Class
Percentage
…
Trustee to Trustee transfer to another Coverdell Education Savings Account. Must attach Letter of Acceptance from succeeding custodian or trustee.
…
Wire transfer to my bank account. Must complete Section 4 and attach a voided check if banking instructions have not been
previously established on the account. A Medallion Signature Guarantee is required.
…
ACH to my bank account. If banking instructions have not been previously established on the account, complete Section 4
and 6 and attach a voided check.
…
Please add banking instructions in Section 4 to my accounts for future distributions.
4
BANKING INSTRUCTIONS (IF APPLICABLE)
This section must be completed if distribution should be electronically sent to your bank account. A voided check or a letter from
the receiving bank detailing bank account information must be attached if instructions are not already on file. Note, ACH instructions and wire instructions are not necessarily the same, and may differ from the routing number on your check. Please verify
instructions with your bank. If bank account receiving your distribution is currently not on file for this account, a Medallion
Signature Guarantee is required in Section 6.
Account Type:
… Checking … Savings
Coverdell ESA Distribution Request Form 2
Tape your voided, imprinted check here.
(Do not staple.)
5
SIGNATURE AND CONFIRMATION
I certify that I am authorized to make these elections and that all information provided is true and accurate. I further certify
that the Custodian, the Legg Mason Funds, or any agent of either of them has given no tax or legal advice to me, and that all
decisions regarding the elections made on this form are my own. The Custodian is hereby authorized and directed to distribute
funds from the account in the manner requested. The Custodian may conclusively rely on this certification and authorization
without further investigation or inquiry. I expressly assume responsibility for any adverse consequences which may arise from
the election(s) and agree that the Custodian, Legg Mason Funds, and their agents shall in no way be responsible, and shall be
indemnified and held harmless, for any tax, legal or other consequences of the election(s) made on this form.
Signature of Responsible or Designated Beneficiary (if of legal age)
6
Print Name
Date
MEDALLION SIGNATURE GUARANTEE (IF REQUIRED)
A Medallion Signature Guarantee is required if the distribution is to be:
• Made payable to someone other than the requested owner
• Mailed to an address other than the current address on file
• The distribution is going to a bank not currently on file
• Mailed to an address that has been changed within 30 days
You can obtain a signature guarantee from most banks, savings institutions, broker/dealers or financial institutions.
NOTARIZATION BY A NOTARY PUBLIC IS NOT ACCEPTABLE IN LIEU OF A MEDALLION SIGNATURE GUARANTEE.
Medallion Signature Guarantee Stamp HERE.
Coverdell ESA Distribution Request Form 3
CONTACT INFORMATION (INCLUDING CUSTOMER COMPLAINTS)
Mail:
Postal address
Overnight carrier address
Legg Mason Funds
P.O. Box 9699
Providence, RI 02940-9699
Legg Mason Funds
4400 Computer Drive
Westborough, MA 01581
Phone:
To speak with an investment professional regarding any of our funds,
please call toll-free: 1-800-822-5544, Monday through Friday, 8:00 am – 5:30 pm (ET)
Fax:
1-508-599-4186
TeleFund:
To access our telephone account management service, please call toll-free:
1-877-6LMFUNDS (1-877-656-3863)
Internet:
www.leggmasonfunds.com
An investor should consider a Fund’s investment objectives, risks, charges and expenses carefully before investing. For a free prospectus, which contains this and other information on any Legg
Mason Fund, visit www.leggmasonfunds.com. An investor should read the prospectus carefully before investing.
© 2014 Legg Mason Investor Services, LLC, distributor. Member FINRA, SIPC
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Coverdell ESA Distribution Request Form 4