5302 / 2525 (Rev. 7/2013) ©2013 Ascensus, Inc.
PART 5. TRANSFER INSTRUCTIONS
TRANSFER OPTIONS (Select one)
One-Time Transfer
Transfer Amount ____________________________ Transfer Date ________________
Entire Coverdell ESA Balance This Transfer Will Close the Current Coverdell ESA
Recurring Transfer
Transfer Amount ____________________________ Transfer Start Date ________________
Frequency (Select one) Monthly Quarterly Semi-Annually Annually Other ________________________________________
MAKE PAYABLE TO
_______________________________________________ as Trustee or Custodian of _____________________________________ Coverdell ESA
Name of Accepting Coverdell ESA Trustee or Custodian Name of Recipient
ASSET HANDLING (Investments identified below will be liquidated immediately unless otherwise specified in the Special Instructions section.)
Asset Description Amount to be Transferred Special Instructions
__________________________________________ ______________________ ___________________________________________________________________
__________________________________________ ______________________ ___________________________________________________________________
__________________________________________ ______________________ ___________________________________________________________________
PART 3. CURRENT DESIGNATED BENEFICIARY
Name (First/MI/Last) __________________________________________
Social Security Number ________________________________________
Account Number__________________________________ Suffix ______
Responsible Individual Name ___________________________________
Responsible Individual Phone ___________________________________
PART 4.
CURRENT COVERDELL ESA TRUSTEE OR CUSTODIAN
Name ______________________________________________________
Address Line 1 _______________________________________________
Address Line 2 _______________________________________________
City/State/ZIP________________________________________________
Phone ______________________________________________________
TRANSFER REQUEST
This form must be completed by the Responsible Individual of the current Coverdell ESA who is requesting the transfer.
COVERDELL
ESA
PART 1. RECIPIENT
Designated beneficiary receiving the transfer
Name (First/MI/Last) __________________________________________
Date of Birth ________________________________________________
Account Number__________________________________ Suffix______
PART 2.
ACCEPTING COVERDELL ESA TRUSTEE OR CUSTODIAN
To be completed by the Coverdell ESA trustee or custodian receiving the assets
Name ______________________________________________________
Address Line 1 _______________________________________________
Address Line 2 _______________________________________________
City/State/ZIP________________________________________________
Phone ________________________ Organization Number___________
Contact Name _______________________________________________
PART 6. SIGNATURES
I certify that I am the proper party to authorize the transfer of these Coverdell ESA assets and certify that all information provided by me is true and
accurate. I understand that I am responsible for determining that this Coverdell ESA transfer qualifies under the rules that apply to such transfers and
agree to comply with those rules. I assume responsibility for any consequences that may result from this transfer and I agree that the trustee or
custodian is not responsible for any consequences that may arise from executing this transfer request.
The trustee or custodian signing below agrees to accept the assets being transferred.
X
_________________________________________________________________________________________________ _______________________________________
Signature of Responsible Individual Date (mm/dd/yyyy)
X
_________________________________________________________________________________________________ _______________________________________
Notary Public/Signature Guarantee (If required by the trustee or custodian) Date (mm/dd/yyyy)
X
_________________________________________________________________________________________________ _______________________________________
Authorized Signature of Accepting Trustee or Custodian Date (mm/dd/yyyy)
