Account Information Change Form

UIIPA MKT4453 PAAIC 0212 Page 1 to 4
Pennsylvania 529 Investment Plan
Account Information Change Form
Complete this form to change the account owner or the name, mailing address, phone number, e-mail address, Successor Account Owner,
or interested party information on your account.
You can also change your mailing address, phone number, e-mail address, successor owner, or interested party by accessing your account
at www.PA529.com.
If you are changing your name, your former signature and new signature must be guaranteed in Section 7 by an authorized officer of a bank,
broker, or other qualified financial institution.
Important: If you are changing the owner of an existing account, you must provide the account number(s) in Section 1. You must also submit an
Enrollment Application completed and signed by the new account owner identified in Section 3.
Print clearly, preferably in capital letters and black ink.
Forms can be downloaded from our website at www.PA529.com. Or you can call us to order any form at 1-800-440-4000. Return this form in the
enclosed envelope, or mail to: Pennsylvania 529 Investment Plan, P.O. Box 55378, Boston, MA 02205-5378. For overnight delivery or registered
mail, send to: Pennsylvania 529 Investment Plan, 95 Wells Avenue, Suite 155, Newton, MA 02459-3204.
1. Current Account Owner Information
Account Number(s)
(To list more than three accounts, use the space below.)
–
–
–
Name of Account Owner (first, middle initial, last) or Trust
–
–
Social Security Number or Other Taxpayer ID Number
–
–
–
Daytime Telephone Number
–
Evening Telephone Number
REMEMBER TO SIGN IN SECTION 7.
* P A
I N F O
1
C H A N G E *
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2. Updated Existing Account Owner Information (if applicable)
If you are changing your contact information, provide the new information exactly as you would like it to appear on your PA 529 Investment
Plan account.
If you are changing your name, you must provide a signature guarantee in Section 7.
New Legal Name of Existing Account Owner (first, middle initial, last)
E-mail Address
–
–
Daytime Telephone Number
–
–
Evening Telephone Number
Permanent Street Address or APO/FPO (A P.O. box is not acceptable.)
–
City
StateZip
Account Mailing Address if Different From Above (used both as the account’s address of record and for all account mailings)
–
City
StateZip
3. Transfer Assets to New Account Owner (if applicable)
This will transfer ownership of these assets to the new account owner listed below.
The new account owner will control the account and the disposition of all assets held in the account.
The new account owner must also complete an Enrollment Application.
Name of New Account Owner (first, middle initial, last) or Trust
–
–
Birth Date/Trust Date (month, day, year)
–
–
Social Security Number or Other Taxpayer ID Number
2
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4. Add/Change/Delete Successor Owner Information
Select One:
Add
Change
Delete
(All information on the proposed new Successor Owner must be completed in order to add or change the Successor Owner.)
Name of Successor Owner (first, middle initial, last)
–
–
–
Birth Date/Trust Date (month, day, year)
–
Social Security Number or Other Taxpayer ID Number
Mailing Address
–
City
StateZip
–
–
Telephone Number
PA Resident (select one)
Yes, County of Residence is
No
5.
Interested Party Information (if applicable)
Complete this section if you want additional persons to receive a quarterly account statement or if you are changing interested party information
on your account. To add or change information for more than one interested party, use a separate sheet. If you wish to grant a person additional
powers to act on this account, complete a Limited Power of Attorney/Agent Authorization Form or Power of Attorney Form.
(Check one.)
Add
Replace
Change current information
Remove
Name (first, middle initial, last)
Mailing Address
–
City
StateZip
–
Telephone Number
–
Relationship
3
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6. SAGE Scholars (optional)
If you or your beneficiary is a Pennsylvania resident, you may opt to participate, at no cost, in the SAGE Scholars College Tuition Rewards Program,
through which you can earn tuition discounts at colleges that participate in SAGE. The discount earned is 2.5% of the PA 529 Investment Plan
account value at the end of each calendar quarter, which accumulates until the beneficiary’s 17th birthday. Each SAGE participating school
determines the maximum discount that it will honor, which currently is between $8,500 and $40,905 (spread evenly
over four years of college).
Your beneficiary is eligible to enroll in the SAGE Scholars Program until he or she is 16 years old.
By enrolling, you will receive $500 in SAGE Tuition Rewards discounts. Visit www.sagescholars.com to learn more.
You must access and register at www.tuitionrewards.com to participate in the SAGE Scholars Program. This is required to verify/
update account holder and student information, as well as to submit the electronic Tuition Rewards statement to member schools when
their beneficiaries are beginning the college application process.
I wish to enroll in the SAGE Scholars Program.
If I have indicated that I wish to enroll in the SAGE Scholars College Tuition Rewards Program by completing this section and submitting this
Account Information Change Form, I am authorizing and directing the PA 529 Investment Plan to provide SAGE Scholars, Inc., with my name,
address, and Social Security number and my beneficiary’s name, address, and Social Security number, as well as my e-mail address and
information on the amount of SAGE Scholars Tuition Rewards discounts to which I am entitled. SAGE Scholars, Inc., will use this information to
administer the SAGE Scholars Tuition Rewards Program and may provide my information to SAGE Scholars member schools so that they may
contact me or my beneficiary.
7.Signature
The current Account Owner must sign below. However, if you are changing your name, skip this section and complete
Section 8 instead.
I certify that the information provided in this form is true and complete in all respects.
–
4 S I G N A T U R E
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Signature of Account Owner Date (month, day, year)
8. One-and-the-Same Signature Guarantee—REQUIRED FOR NAME CHANGES ONLY
If you are changing your name, your former signature and your new signature must be guaranteed by an authorized officer of a bank, broker,
or other qualified financial institution. A notary public cannot provide a signature guarantee, and you cannot guarantee your own signature.
Do not sign below until you are in the presence of the authorized officer providing the signature guarantee.
I certify that the information provided in this form is true and complete in all respects.
–
4 S I G N A T U R E
–
Former Signature of Account OwnerDate (month, day, year)
–
4 S I G N A T U R E
–
New Signature of Account OwnerDate (month, day, year)
4
Authorized Officer to Place Stamp Here
Signature of Guarantor
Title/Name of Institution
–
–
Date (month, day, year)
© 2012 Commonwealth of Pennsylvania. 4