Fillable ESA CONTRIBUTION AND INVESTMENT SELECTION (Georgia's Own Credit Union)

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ESA CONTRIBUTION AND INVESTMENT SELECTION (Georgia's Own Credit Union)

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Page 1 of 2
5107 / 2514E (Rev. 10/2014) ©2014 Ascensus, Inc.
CONTRIBUTION AND INVESTMENT SELECTION
PART 1. DESIGNATED BENEFICIARY
Name (First/MI/Last) __________________________________________
Social Security Number ________________________________________
Date of Birth _________________________________________________
Account Number__________________________________ Suffix______
PART 2. COVERDELL ESA TRUSTEE OR CUSTODIAN
To be completed by the Coverdell ESA trustee or custodian
Name ______________________________________________________
Address Line 1 _______________________________________________
Address Line 2 _______________________________________________
City/State/ZIP ________________________________________________
Phone ________________________ Organization Number ___________
PART 3. CONTRIBUTION INFORMATION
Contribution Amount ____________________________ Contribution Date ________________
CONTRIBUTION TYPE (Select one)
1. Regular Contribution for Tax Year _________
2. Rollover (Distribution from a Coverdell ESA that is being deposited into this Coverdell ESA)
By selecting this transaction, I irrevocably designate this contribution as a rollover.
3. Transfer (Direct movement of assets from a Coverdell ESA into this Coverdell ESA)
CONTRIBUTOR INFORMATION
Name (First/MI/Last) ___________________________________________ Phone _________________________
PART 4. INVESTMENT AND DEPOSIT INFORMATION
INVESTMENT INFORMATION (This section may only be completed by the responsible individual. Complete this section as applicable.)
Investment Description Quantity Status Investment Term Interest
or Amount (new or existing) Number or Maturity Date Rate
_______________________________________________ ____________________ ___________ ________________________ ______________ ____________
_______________________________________________ ____________________ ___________ ________________________ ______________ ____________
_______________________________________________ ____________________ ___________ ________________________ ______________ ____________
DEPOSIT METHOD
Cash or Check
(If the contribution type is transfer, the check must be from a financial organization made payable to the trustee for this Coverdell ESA.)
Internal Account
Account Number _____________________________________________ Type (e.g., checking, savings, Coverdell ESA) _________________________
External Account (e.g., EFT, ACH, wire) (Additional documentation may be required and fees may apply.)
Name of Organization Sending the Assets ____________________________________________ Routing Number (Optional)____________________
Account Number _____________________________________________ Type (e.g., checking, savings, Coverdell ESA) _________________________
Deposit Taken by_____________________________________
PART 5. SIGNATURE
I certify that all of the information provided by me is accurate and may be relied upon by the trustee or custodian. I certify that the contribution
described above is eligible to be contributed to the Coverdell ESA and I authorize the deposit to be invested in the manner described above.
X
_________________________________________________________________________________________________ _______________________________________
Signature of Coverdell ESA Contributor/Responsible Individual Date (mm/dd/yyyy)
COVERDELL
ESA
Page 2 of 2
5107 / 2514E (Rev. 10/2014) ©2014 Ascensus, Inc.
RULES AND CONDITIONS APPLICABLE TO COVERDELL ESA CONTRIBUTIONS
Coverdell ESA contribution rules are often complex. The general rules are listed below. If you have any questions regarding a contribution, please
consult with a competent tax professional or refer to IRS Publication 970, Tax Benefits for Higher Education, for more information. This publication is
available on the IRS website at www.irs.gov or by calling 1‐800‐TAX‐FORM.
REGULAR
The total amount that may be contributed to a Coverdell ESA for any tax year cannot exceed the published annual limit.
• Contributions to a Coverdell ESA on behalf of a designated beneficiary can be made by anyone whose income does not exceed certain limits.
• Generally, regular contributions may be made to Coverdell ESAs for a designated beneficiary under 18 years of age.
ROLLOVER
A rollover is a distribution and a subsequent tax‐free movement of assets from one Coverdell ESA to another Coverdell ESA.
• Effective for distributions taken on or after January 1, 2015, only one distribution from any of a designated beneficiary's Coverdell ESAs may be
rolled over in a 12‐month period, regardless of the number of Coverdell ESAs the designated beneficiary owns.
• A rollover generally must be completed within 60 days from the date the assets are received.
• Generally, assets may be rolled over to another Coverdell ESA of the same designated beneficiary or to a qualified family member’s Coverdell ESA.
TRANSFER
A transfer is a direct movement of assets from one Coverdell ESA to another Coverdell ESA.
• An unlimited number of transfers may be performed.
• Generally, assets may be transferred to another Coverdell ESA of the same designated beneficiary or to a qualified family member’s Coverdell ESA.
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ESA CONTRIBUTION AND INVESTMENT SELECTION (Georgia's Own Credit Union)

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Completed 23 December 2020

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