Coverdell Education Savings Account Distribution Form

Print
Please remember to sign
application after printing.
Clear Form
Coverdell Education Savings Account Distribution Form
Use this form to request a distribution from an Invesco Coverdell Education Savings Account
(Coverdell ESA). We recommend that you speak with a tax or financial advisor regarding the
consequences of this transaction.
• Do not use this form to change the designated beneficiary. Please use the Coverdell ESA
Administration Form.
•T
he designated beneficiary may sign as the responsible individual upon reaching the age of majority
in his or her state of residence.
Start
here >.
Use
"Tab"
key to
move to
next
field.
PLEASE USE BLUE OR BLACK INK
PLEASE PRINT CLEARLY IN BLOCK CAPITAL LETTERS
1 |Account Information
A. Designated Beneficiary
Social Security Number (Required)
Date of Birth (mm/dd/yyyy)
Full Name (Please print name as it appears on account.)
Invesco Account Number
B. Responsible Individual
Full Name (Please print name as it appears on account.)
Primary Phone Number
Email Address
2 |Reason for Distribution (Required. Select one.)
Note: Invesco Investment Services, Inc. (IIS) will default to Education Expenses, unless specified below. Refer to the Additional
Information section for important details regarding your distribution.
Education Expense - This includes qualifying and nonqualifying distributions. (Complete sections 3 and 6-8.)
Removal of Excess - (Complete sections 4 and 6-8.)
Transfer of Assets - Responsible individual is transferring assets to a Coverdell ESA for the same beneficiary at a new
custodian. (Complete sections 3 and 6-8.)
Distribution to a 529 plan - (Signature guarantee required. Complete sections 3 and 6-8.)
Death - Designated beneficiary has died. (Complete sections 5-8.)
3 |Distribution Instructions (Complete sections A and B.)
A. Amount of Distribution: (Select one.)
Distribute the entire account.
­I would like to receive the following dollar amount from the account (net): $
,
.
.
I authorize and direct IIS to redeem additional fund shares in amounts necessary to pay any applicable contingent deferred
sales charges. (If you select the one-time distribution frequency below, this will be the amount of your one-time distribution.
If you select the periodic distribution frequency below, this will be the amount of each installment.)
Distribute the following dollar amount from the account (gross): $
,
.
. I understand that
the amount of the distribution that I receive will be reduced by any applicable contingent deferred sales charges. (If you
select the one-time distribution frequency below, this will be the amount of your one-time distribution. If you select the
periodic distribution frequency below, this will be the amount of each installment.)
CESA-FRM-4-E 06/16
1 of 6
*DEFKDSSREDEX*
PLEASE USE BLUE OR BLACK INK
PLEASE PRINT CLEARLY IN BLOCK CAPITAL LETTERS
B. Frequency: (Select one option. IIS will default to a one-time distribution unless specified below.)
One-time distribution.
I wish to establish a series of periodic distributions. (Select one option below.)
Note:
• The account from which the periodic distribution is taken must have a minimum balance of $5,000.00. The amount
requested for distribution must be at least $50 per fund.
• If the selected date has already passed, IIS will establish your plan for the next scheduled payment date.
• IIS will default to the 10th, unless specified below.
Monthly - One draft per month on the following day of the month _________ (e.g., 10th, 25th, etc.) beginning in
______________________ (month) ___________ (year).
Quarterly - One draft per quarter on the following day of the month _________ (e.g., 10th, 25th, etc.) beginning in
______________________ (month) ___________ (year).
Annually - One draft per year on the following day of the month _________ (e.g., 10th, 25th, etc.) beginning in
______________________ (month) ___________ (year).
4 |Removal of Excess (Select one.)
The designated beneficiary may be subject to a 6% excise tax penalty, imposed by the IRS, on the amount of the excess each
year, until the excess is corrected. The deadline for removing the excess to avoid the penalty is May 31st of the year following
the year in which the excess contribution was made (no extension).
Removing Excess Prior to May 31st Deadline. I understand that I must remove both the excess amount as well as
the earnings, if any. The earnings will be taxable to the designated beneficiary in the calendar year in which the
contribution was deposited.
1. Amount of excess contribution $
,
.
which was deposited in calendar year
.
2. Earnings amount (Select one. IIS will default to calculating the earnings, unless specified below.)
I would like IIS to calculate the earnings portion and distribute this amount.
I have calculated the earnings $
,
.
.
Removing Excess After May 31st Deadline. I understand that only the amount of excess contribution will be removed.
The excess amount will be treated as an educational distribution following qualified/non-qualified guidelines. Non-qualified
educational distributions may be taxable and subject to a 10% additional tax.
Amount of excess contribution $
,
.
which was deposited in calendar year
.
5 |Death Distribution Information (Complete sections A and B.)
A medallion signature guarantee is required in section 8. If you are unable to obtain a medallion signature guarantee, please
see the Additional Information section at the end of this form for alternative requirements.
Designated Beneficiary’s Date of Death (mm/dd/yyyy)
A. Death Beneficiary (Select one.)
The Death Beneficiary is the person or entity named on the account to receive the assets upon the death of the Designated
Beneficiary.
Family member under age 30 (as defined by the Internal Revenue Code. This age requirement does not apply to special
needs individuals.)
Non-Family member or a family member over age 30
Entity
Full Name/Name of Entity
Social Security Number
(or Tax Identification Number if Beneficiary is Entity. Required.)
Date of Birth (mm/dd/yyyy)
Executor/Trustee/Personal Representative Name if Death Beneficiary is Entity (Please print.)
CESA-FRM-4-E 06/16
2 of 6
PLEASE USE BLUE OR BLACK INK
PLEASE PRINT CLEARLY IN BLOCK CAPITAL LETTERS
Mailing Address (Including apartment or P.O. Box number.)
City
StateZIP
Primary Phone Number
Email Address
Residential Address (Required if different from mailing address or if a P.O. Box was given above.)
City
StateZIP
B. Transfer/Distribution Instructions: (Select one.)
Distribute the entire account.
ransfer the proceeds to another Coverdell ESA (Only available for a family member under age 30. This age requirement
T
does not apply to special needs individuals.)
6 | Allocation of Distribution (Select one. IIS will default to proportionate, unless specified below.)
­­Proportionate: Shares will be redeemed from each fund proportionate to that fund’s value with respect to the total value of
your account.
­­Distribution From Specific Fund(s): Please indicate the fund(s) and redemption amounts below.
Fund Number Fund Name Percentage
Amount
or $
,
.
or $
,
.
or $
,
.
7 | Payment Options (Refer to section 8 to determine if a signature guarantee is required.)
Note: Your distribution will be mailed to the address of record unless specified below. Checks will not be forwarded.
Select only one payment option (option A, B, or C).
A. By Check:
Mail check to the designated beneficiary’s address of record.
Mail check to the new Coverdell ESA custodian or plan trustee per attached letter of acceptance from the new custodian.
(Signature guarantee not required.)
Mail check to third party address (this includes checks payable to a 529 plan or to a death beneficiary; signature
guarantee required in section 8.)
Make check payable to:
Mailing Address (Including apartment or P.O. Box number.)
City
CESA-FRM-4-E 06/16
StateZIP
3 of 6
PLEASE USE BLUE OR BLACK INK
PLEASE PRINT CLEARLY IN BLOCK CAPITAL LETTERS
B. To Bank: (If banking information is provided below and a delivery option is not selected, proceeds will be sent via
Automated Clearing House (ACH).)
­­Wire proceeds to my bank account. (Not available for periodic distributions.)
­­ACH Transfer to my bank account. (Allow 2-3 business days to receive your proceeds.)
Please provide bank instructions below. In doing so, shareholders with eligible accounts are allowed to make investments
into their fund by calling an Invesco Client Services representative. Upon request, IIS can arrange for a specified dollar
amount to be deducted from your bank account via ACH and used to purchase shares of a specified fund. These bank
instructions will also be used for systematic purchase and may receive redemption proceeds as requested.
Note:
• Unless instructed otherwise, IIS will replace your current systematic bank information with the new bank information
provided below.
• Signature of bank account owner(s) is required in section 8 if different from account registration.
• Temporary or starter checks are not acceptable.
• If a voided company or corporate check is provided, then a letter from that financial institution verifying the authorized
signers must be included.
Account Type:
Checking
Savings
Name
Pay to the order of
$
Please tape your voided check here.
Routing Number
Account Number
C. Deposit into an Invesco Account:
­­Transfer the proceeds in kind into an Invesco Coverdell ESA for the death beneficiary. (Please include account number or
attach a completed Invesco Coverdell Education Savings Account Application. Your fund selection will remain the same.)
Invesco Coverdell ESA Account Number
D
­­ eposit the proceeds of a removal of excess distribution as a contribution into an Invesco Coverdell ESA account of another
designated beneficiary in kind. (Available only for Removal of Excess Distributions. Please include account number or attach
a completed Invesco Coverdell Education Savings Account Application. Your fund selection will remain the same.)
Invesco Coverdell ESA Account Number
Contribution is for year:
(IIS will default to current year, unless specified.)
eposit the proceeds into a new Invesco account (other than Coverdell ESA) in kind. (Please complete and attach the
­­D
appropriate Invesco application. Your fund selection will remain the same.)
­­Deposit the proceeds into my existing Invesco account (other than Coverdell ESA) in the following funds. (Exchanges
must be for shares of the same share class.)
Fund Number CESA-FRM-4-E 06/16
Account Number Percentage
Amount
or $
,
.
or $
,
.
or $
,
.
or $
,
.
4 of 6
PLEASE USE BLUE OR BLACK INK
PLEASE PRINT CLEARLY IN BLOCK CAPITAL LETTERS
8 | Authorization and Signature (Please sign and date below.)
Responsible Individual Authorization:
I affirm that the information given is true and correct, and I authorize and direct the custodian to make distributions according
to the instructions provided on this form.
Death Beneficiary Authorization:
I affirm that the information given is true and correct, and I authorize and direct the custodian to distribute/transfer my
portion of the assets according to the instructions provided on this form.
Note: Death beneficiary’s signature is required unless the death beneficiary is a minor, in which case, the responsible
individual’s signature is required.
Designated Beneficiary Reaching Age of Majority:
• I understand that I will become both the responsible individual and the designated beneficiary.
• Under penalties of perjury, I certify that I am the beneficial owner of the account indicated in section 1 and I have reached
the legal age of majority designated under my state of residence,
• I understand and agree that the custodian may amend the Custodial Agreement by providing me written notice of any such
amendment and that the mutual funds in which I invest may and will amend their prospectuses from time to time.
• I consent to the custodial fees specified, and I understand that a $15 maintenance fee will be deducted annually from
the account if the balance of the account is less than $50,000 on the day the fee is assessed.
Note: If the designated beneficiary has reached the age of majority and is signing as the responsible individual, a medallion
guarantee is required below. If you are unable to obtain a medallion signature guarantee, please see the Additional
Information section at the end of this form for alternative requirements.
Request for Taxpayer Identification Number (Substitute Form W-9)
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued
to me), and
2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified
by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest
or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and
3. I am a U.S. person (including a U.S. resident alien), and
4. I am exempt from FATCA reporting.
Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently
subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real
estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property,
cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than
interest and dividends, you are not required to sign the certification, but you must provide your correct TIN.
Signature (Required)
Date (mm/dd/yyyy)
x
A signature guarantee is required under the following circumstances:
• Redemption proceeds will exceed $250,000 per fund.
• Redemption proceeds to be paid to someone other than the designated beneficiary or the responsible individual on the
account.
• Redemption proceeds to be sent somewhere other than the address of record or bank of record on the account.
• Proceeds of an unscheduled redemption will be sent to a bank account or address of record that has been on the Invesco
account for less than 15 days.
Signature Guarantee: (Please place signature guarantee stamp below.)
Note: Endorsement guarantee is not acceptable.
CESA-FRM-4-E 06/16
5 of 6
Each signature must be guaranteed by a bank,
broker-dealer, savings and loan association, credit
union, national securities exchange or any other
“eligible guarantor institution” as defined in rules
adopted by the Securities and Exchange Commission.
Signatures may also be guaranteed with a medallion
stamp of the STAMP program or the NYSE Medallion
Signature Program, provided that the amount of
the transaction does not exceed the relevant surety
coverage of the medallion. A signature guarantee
may NOT be obtained through a notary public.
PLEASE USE BLUE OR BLACK INK
PLEASE PRINT CLEARLY IN BLOCK CAPITAL LETTERS
9 | Mailing Instructions
Please send completed and signed form to:.
(Direct Mail)
Invesco Investment Services, Inc.
P.O. Box 219078
Kansas City, MO 64121-9078
(Overnight Mail)
Invesco Investment Services, Inc.
c/o DST Systems, Inc.
430 W. 7th Street
Kansas City, MO 64105-1407
For additional assistance please contact an Invesco Client Services representative at 800 959 4246, weekdays,
7 a.m. to 6 p.m. Central Time.
Visit our website at invesco.com/us to:
• Check your account balance
• Confirm transaction history
• View account statements and tax forms
• Sign up for eDelivery of statements, daily transaction
statements, tax forms, prospectuses, and reports
• Check the current fund price, yield and total return on any fund
• Process transactions
• Retrieve account forms and investor education materials
Call the 24-Hour Automated Investor Line 800 246 5463 to:
• Obtain fund prices
• Confirm your last three transactions
• Order a recent account statement(s)
• Check your account balance
• Process transactions
To use the system, please have your account numbers and Social Security number available.
Additional Information
Additional Documentation Requirements
If you are not able to obtain a medallion signature guarantee, a signature guarantee is required in section 8 of this form along
with some of the following additional documentation (as applicable):
•A
certified copy of the designated beneficiary’s death certificate or a certified copy of letters testamentary indicating the
designated beneficiary’s date of death.
• An heir or devisee of the designated beneficiary claiming assets pursuant to a small estate administration must provide a
certified copy of the affidavit of small estate (in states where applicable).
• A certified copy of the birth certificate for designated beneficiary who has reached the legal age of majority under his or
her state of residence.
Transfer to a Coverdell ESA at Another Custodian
IIS requires a letter of acceptance to transfer assets to a Coverdell ESA held with another custodian. The letter of acceptance
should indicate that the assets will be transferred into a Coverdell ESA for the same designated beneficiary.
Distributions
If you selected anything other than Removal of Excess or Death in section 2 as the reason for distribution, this will report as
distribution code 1 Distribution on Form 1099-Q. It is the Responsible Individual’s responsibility to report the distribution as
qualified or non-qualified to the IRS. For more information refer to IRS Publication 970 at irs.gov.
ualified - Distributions used to pay for qualified education expenses, including contributions to a 529 plan, for the designated
•Q
beneficiary. Distribution must occur prior to age of 30. Special needs designated beneficiaries are not subject to the age
requirement.
•N
on-qualified - Distributions used for non-qualified expenses are subject to 10% additional tax penalty on the taxable portion.
CESA-FRM-4-E 06/16
6 of 6