529 Rollover Form.indd

P.O. Box 198801
Nashville, TN 37219
615-741-1502 (local)
1-855-386-7827 (toll-free)
615-401-6816 (fax)
E-mail: [email protected]
Website: www.tnstars.com
State of Tennessee
Treasury Department
College Savings 529 Program
Rollover Form
Instructions
Please use this form to rollover assets from another Section 529 Plan. Before you complete this form, please
complete the TN Stars College Savings 529 Program Enrollment Application available on-line.
Print clearly in all CAPITAL LETTERS using blue or black ink. When requested, please color in circles completely.
Please mail or fax this completed form and any required documents to the address above.
NOTE: Special consideration should be taken when selecting a new Designated Beneficiary as multiple rollovers
with a 12-month period or the designation of a beneficiary who is not a Qualified Family Member may result in
additional taxes or penalties. See the Plan Disclosure and Participation Agreement for potential tax consequences
and other considerations.
If you have any questions, please call us at 615-741-1502 or toll-free at 1-855 3TN-STAR (1-855-386-7827), Monday
through Friday from 8:00 a.m. to 4:30 p.m. Central Time.
1. Account Information
All information in this section is required.
__________________________________________
Account Number
______________________________________________________
Account Owner’s Name (first, middle initial, last)
__________________________________________
Social Security or U.S. Taxpayer ID Number
___________________________________________________________________________________________________________
Street Address (no P.O. Boxes)
City
State
Zip Code
___________________________________________________________________________________________________________
Daytime Phone Number
Alternate Phone Number
___________________________________________________________________________________________________________
E-Mail Address
___________________________________________________________________________________________________________
Beneficiary’s Name (first, middle initial, last)
______________________________________________________
Beneficiary’s Social Security Number
__________________________________________
Beneficiary’s Date of Birth (mm/dd/yyyy)
Is the beneficiary named above different from the beneficiary on your current TN Stars College Savings 529
Account?
Yes
No
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2. Instructions to Current/Resigning Trustee
A. Indicate the Source of your Rollover/Transfer (check one)
Section 529 College Savings Plan
Qualified Savings Bonds
B. Indicate whether this is an Indirect Rollover or a Direct Rollover Request (Check one and complete additional
information as requested for a Direct Rollover. Note that a Direct Rollover is only permissible for assets held in
the TN Stars College Savings 529 Program or another Section 529 College Savings Plan account.)
Indirect Rollover: I am enclosing a check representing the rollover proceeds.
Direct Rollover: I am requesting and instructing the TN Stars College Savings 529 Program to act on
my behalf to obtain funds directly from the trustee of my current Section 529 College Savings Program
Account. For a Direct Rollover, please fill in the information requested below and include a copy of your
current account statement. Your current Program Manager may require additional information.
_______________________________________________
Name of Current Program Manager/529 Plan
__________________________________________
Account Number
____________________________________________________________________________________________________
Street Address or P.O. Box
City
State
Zip Code
_______________________________________________
Phone Number
__________________________________________
State Sponsor (if applicable)
Full Account
Partial Account (select one of the following)
Dollar Amount $_______________________
Percentage _________________________%
C. Indicate which portion of the Rollover is attributable to contributions (cost basis) and which is attributable to
earnings. Otherwise, your entire Rollover is required to be treated as earnings, which may be taxable upon
withdrawal. If you do not know this amount, your Program Manager must send this information with a direct
rollover check. (For further details, call your Program Manager.)
$_________________________ Total Amount of Rollover/Transfer
$_________________________ Base Contribution or Cost Basis of Rollover/Transfer
$_________________________ Earnings Portion of Rollover/Transfer
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D. Please indicate whether you would like to allocate your funds differently from the way you did in the Elected
Investment Allocation on your Account Application for the TN Stars College Savings 529 Program. Please note
this will only affect your rollover dollars.
Investment Options
Allocation
Age-Based Portfolios (One Age-Based Portfolio can be chosen per account.)
0-4
%
5 - 10
%
11 - 14
%
15 - 17
%
18 +
%
Self-Selected Portfolios
TN DFA Enhanced U.S. Large Company Portfolio Institutional Class
%
TN Vanguard 500 Index Signal Shares
%
TN Maxim American Century Growth Fund
%
TN PRIMECAP Odyssey Aggressive Growth Fund
%
TN Vanguard Mid-Cap Growth Investor Shares
%
TN DFA Large-Cap International Portfolio Institutional Class
%
TN DFA Inflation-Protected Securities Portfolio Institutional Class
%
TN Vanguard Total Bond Market Signal Shares
%
TN Vanguard Intermediate-Term Investment-Grade Fund Admiral Shares
%
TN Vanguard Intermediate-Term Treasury Admiral Shares
%
TN Vanguard Wellington Investor Shares
%
TN Vanguard Life Strategy Conservative Growth Fund
%
TN Vanguard Life Strategy Income Fund
%
First TN Interest Bearing Account Option
%
Total
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3. Signatures
I authorize the TN Stars College Savings 529 Program to act on my behalf in contacting the current 529 Plan
Program Manager to facilitate the transfer of assets. I hereby certify that (1) the information provided herein is
accurate, (2) the Designated Beneficiary on my TN Stars College Savings 529 Program Account is a “member of
the family” of the Designated Beneficiary in the current program (as defined in the Plan Description and Savings
Trust Agreement) or (3) this Rollover does not change the Beneficiary and is the only Rollover for the Beneficiary
within the past 12 months and, if applicable, (4) my contribution of rollover proceeds from another account is
within 60 days of receiving the refund. I understand that, if I fail to provide the required information relative to
the contributions and earnings portion of the rollover mentioned in Section 2C, the entire amount of the rollover
contribution will be treated as earnings that may be taxable upon withdrawal.
__________________________________________________
Signature of Account Owner, Custodian,
Trustee, Partner or Officer
_________________________________________________
Date
4. Signature Guarantee
A signature guarantee is a warranty by a participant in a Securities Transfer Association Signature Guarantee
Program that the signature is genuine and that the person signing is competent and authorized to sign. Many
domestic banks or trust companies, credit unions, brokers, dealers, national securities exchanges, registered
securities associations, clearing agencies or savings associations participate in such programs.
Call your Program Manager to determine if a signature guarantee is required.
Affix stamp here.
_______________________________________
Signature of Guarantor
______________________________________
Title
____________________
Date
5. Before You Mail, Have You ...
Completed a TN Stars College Savings 529 Program Application, if you are opening a new account?
Included documents from your current Program Manager, if required?
Written a check payable to “TN Stars College Savings 529 Program” for an Indirect Rollover?
Signed this form in Section 3?
Obtained a Signature Guarantee, if required, in Section 4?
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