DO NOT STAPLE
4
ES_NYA_BC_1208120 — Page 4 of 4
5.
Successor Account Owner information
• The Successor Account Owner will take over control of the Account in the event of your death.
• You may revoke or change the Successor Account Owner at any time. See the Disclosure Booklet for more information.
I want to have the same Successor Account Owner for the new Beneciary.
I want to establish a new Successor Account Owner for the new Beneciary, provided below.
Name (rst, middle initial, last)
Birth Date (mm/dd/yyyy)
6.
Recurring Contributions (Optional)
Through Recurring Contributions, you can have funds transferred electronically — on a regular basis — from your bank, savings and
loan, or credit union account to your Plan Account. Your contribution will be credited to your Plan Account on the same business day it
is debited from your bank account. You may download a Recurring Contributions/Electronic Bank Transfer Form to add, change,
or delete bank information, or change the investment amount and frequency at any time by logging on to your Account at
www.ny529advisor.com or by calling 1.800.774.2108.
I would like to continue my existing Recurring Contributions for the new Beneciary.
7.
SIGNATURE — YOU MUST SIGN BELOW
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 the Disclosure Booklet and the Plan forms signed by me constitute the entire agreement between the Account
Owner and the Plan. No person is authorized to make an oral modication to this agreement.
• I understand that I may incur federal, state or local income and penalty taxes as a consequence of certain activities, including
without limitation non-qualied withdrawals, terminating my Account, or changing my Beneciary to an ineligible person. Account
Owners should seek advice from a qualied tax professional.
• 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 afliates, 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 specic 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 the Investment Options offered by the Plan have been designed to save for post-secondary higher education expenses
and that for New York State tax purposes, the earnings on a withdrawal used to pay K-12 Expenses, Apprenticeship Program
Expenses, or Qualied Education Loan Expenses will be considered a nonqualied withdrawal and will require the recapture of any
New York State tax benets that have accrued on contributions.
• I understand that contributions that cause the total balance of this Account and any other Accounts established in the Plan and in
any other Qualied Tuition Program offered by the State of New York on behalf of the Beneciary 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.
• all the information that I provided on this form is true and accurate in all material respects, that Ascensus and its afliates are
entitled to rely on the information provided herein and the instructions provided on this form, and that I am bound by any and all
statutory, administrative, and operating procedures that govern the Plan.
SIGNATURE
Signature of Account Owner Date (mm/dd/yyyy)
529-F-BENECHANGE 1220
