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CSNYA_FRM_01189H 0215 — Page 3 of 3
DO NOT STAPLE
I authorize the Advisor-Guided Plan to exchange from the following Investment Option
$
, .
From Investment Option Amount* ($100 minimum)
Important: This is the Portfolio to which your enclosed contribution will be allocated. This will not change future allocation
instructions on file.
To the following Investment Options
$
, .
To Investment Option Amount* ($100 minimum per Portfolio)
$
, .
To Investment Option Amount* ($100 minimum per Portfolio)
$
, .
To Investment Option Amount* ($100 minimum per Portfolio)
*Amount per Portfolio per frequency selected above. Please specify only dollar amounts, not percentages.
3. Signature
By signing below, I hereby certify that:
• I have received the Disclosure Booklet and Tuition Savings Agreement of New York’s 529 Advisor-Guided College Savings Program
(“Disclosure Booklet”). I understand that by signing this form, I am agreeing to be bound by the terms and conditions of the
Disclosure Booklet. I understand that the New York’s 529 Advisor-Guided College Savings Program (“Plan”) may from time to time
amend the Disclosure Booklet, and I agree I will be subject to the terms of those amendments. I understand that the Disclosure
Booklet and this form shall be construed, governed, and interpreted in accordance with the laws of the State of New York.
• I understand that contributions to the Plan are not insured and that the investment returns are not guaranteed by the Federal Deposit
Insurance Corporation, the State of New York, its agencies, or any other government or government agency, Ascensus Broker Dealer
Services, Inc., and its affiliates, JP Morgan Distribution Services, Inc., or the investment managers for the underlying funds in the
Plan. There is no assurance that the Accounts under the Plan will generate any specific rate of return; and there is no assurance that
the Account will not decrease in value. I understand that I could lose money.
• I understand that contributions that cause the total balance of this Account and any other Accounts established in the Plan and in
any other Qualified Tuition Program offered by the State of New York on behalf of the Beneficiary to exceed the Maximum Account
Balance set forth in the Disclosure Booklet are not permitted. I understand that if a contribution is made to my Account that exceeds
the Maximum Account Balance, all or a portion of the contribution amount will be returned to me or the contributor.
SIGNATURE
Signature of Account Owner (If the Account Owner is a minor, the designated parent or guardian must sign.) Date (mm/dd/yyyy)
529-F-ADDCON 0315
