Fillable Enrollment Application

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Enrollment Application

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The Enrollment Application form is 8 pages long and contains:

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  • 7 check-boxes
  • 125 other fields

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File type: PDF

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ES_PAD_EN_022621 — Page 1 of 8
1
Account Type
Select one of the account types below. If you do not select an account type, we will open an individual account for you.
Individual account.
UGMA/UTMA account. I am opening this account with assets liquidated from an UGMA/UTMA custodial account. I understand
that this may be a taxable event.
Indicate the state (please abbreviate) under the laws of which the UGMA/UTMA custodial account was opened.
Trust account. I am opening this account under an existing trust. (You must include a copy of the entire trust document, including
the name and date of the trust and the names ands signatures of the trustees.)
IMPORTANT INFORMATION ABOUT OPENING A NEW ACCOUNT. We are required by federal law to obtain from each person who
opens an account certain personal information—including name, street address, and date of birth, among other information—that will be
used to verify identity. If you do not provide us with this information, we will not be able to open the account. If we are unable to verify your
identity, we reserve the right to close your account or take other steps we deem reasonable.
• Complete this form to establish an account, or open an account at www.PA529.com.
• Your initial investment, including contributions by check, transfer, or rollover, must total at least $10.
• Print clearly, preferably in capital letters and black ink.
To order any form—or get assistance in lling out this one—call us at 1-800-440-4000. Return this form and any other required documents
to: Pennsylvania 529 Investment Plan, P.O. Box 55378, Boston, MA 02205-5378. For overnight delivery or registered mail, send to:
Pennsylvania 529 Investment Plan, 95 Wells Avenue, Suite 155, Newton, MA 02459-3204.
Pennsylvania 529 Investment Plan
Enrollment Application
REMEMBER TO SIGN IN SECTION 12.
2
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2.
Account Owner Information (This individual or trust owns and controls the account. The individual must be at
least 18 years old.)
Name of Individual or Custodian (rst, middle initial, last), or Trust
Social Security or Taxpayer Identication Number Birth Date/Trust Date (mm-dd-yyyy)
Citizenship (If not a U.S. citizen, please indicate country of citizenship.):
Daytime Telephone Number Evening Telephone Number
Email Address
Permanent Street Address or APO/FPO (A P.O. box is not acceptable.)
City State Zip Code
Account Mailing Address if Different From Above (used both as the account’s address of record and for all account mailings)
City State Zip Code
3.
Beneciary Information (This individual is the future student.)
You may select only one beneciary per account.
Name (rst, middle initial, last)
Social Security or Taxpayer Identication Number Birth Date (mm-dd-yyyy)
Citizenship (If not a U.S. citizen, please indicate country of citizenship.):
4.
Successor Owner Information (Optional) (This individual will take control of your account in the event of your
death or incapacity.)
• You may revoke or change the Successor Owner at any time. Refer to the PA 529 Investment Plan Disclosure Statement (Disclosure
Statement) for more information.
• You can have only one Successor Owner per account, and he or she must be a U.S. citizen or resident alien and must be at least 18
years of age.
Name (rst, middle initial, last)
Birth Date (mm-dd-yyyy)
3
ES_PAD_EN_022621 — Page 3 of 8
5.
Investment Selection
• You can invest your contributions in the PA 529 Investment Plan’s target enrollment portfolios, individual portfolios, or a combination
of these. Refer to the Disclosure Statement for more information.
• You may choose up to ve of the investments listed below.
• You must allocate at least 5% of your contributions to each investment you choose, using whole percentages only.
• Your investment percentages must total 100%.
Target Enrollment Portfolios: (Your investment mix automatically becomes more conservative as the beneciary nears the target
enrollment year.)
Pennsylvania Target Enrollment 2038/2039 Portfolio
%
Pennsylvania Target Enrollment 2036/2037 Portfolio
%
Pennsylvania Target Enrollment 2034/2035 Portfolio
%
Pennsylvania Target Enrollment 2032/2033 Portfolio
%
Pennsylvania Target Enrollment 2030/2031 Portfolio
%
Pennsylvania Target Enrollment 2028/2029 Portfolio
%
Pennsylvania Target Enrollment 2026/2027 Portfolio
%
Pennsylvania Target Enrollment 2024/2025 Portfolio
%
Pennsylvania Target Enrollment 2022/2023 Portfolio
%
Pennsylvania Target Enrollment 2020/2021 Portfolio
%
Pennsylvania Commencement Portfolio
%
Individual Portfolios
Stock Portfolios:
Aggressive Growth Portfolio
%
Total International Stock Index Portfolio
%
Total Stock Market Index Portfolio
%
Social Index Portfolio
%
Real Estate Index Portfolio
%
Balanced Portfolios:
Growth Portfolio
%
Moderate Growth Portfolio
%
Conservative Growth Portfolio
%
Income Portfolio
%
Bond Portfolios:
Conservative Income Portfolio
%
Total Bond Market Index Portfolio
%
Total International Bond Index Portfolio
%
Short-Term Investment Portfolios:
Interest Accumulation Portfolio
%
Short-Term Ination Protected Securities Index Portfolio
%
Total
%
001
• Please remember to:
• Choose no more than
ve investments for your
account.
• Allocate at least 5% to
each investment you
choose.
• Use whole percentages.
4
ES_PAD_EN_022621 — Page 4 of 8
6.
Initial Contribution
• The minimum initial contribution is $10.
• If you send one check that combines contributions from more than one source (for example, a $5,000 check that includes $2,500 from
your bank account and $2,500 from an education savings account), mark each contribution source in the appropriate box below and
indicate the amount to be attributed to each.
• Contributions and rollovers by check will not be available for withdrawal for seven business days. Contributions by electronic bank
transfer will not be available for withdrawal for ve business days.
Source of funds (Check all that apply.)
A. Personal check. Make your check payable to PA 529 Investment Plan. The PA 529 Investment Plan will not accept
contributions made by starter check, bank courtesy check, instant loan check, credit card check, traveler’s check, foreign check
not in U.S. dollars, checks dated over 180 days in the past, post-dated checks, third-party checks greater than $10,000, checks
with unclear instructions, or any other check the PA 529 Investment Plan deems unacceptable.
$
, .
Amount
B. Electronic bank transfer (EBT). To set this up, you must provide bank information in Section 8.
$
, .
This amount will be your one-time EBT contribution to open your account.
Amount
C. Direct rollover from another qualied 529 plan. Complete and attach an Incoming Rollover Form, which is available online
at www.PA529.com or by calling 1-800-440-4000. Rollovers between 529 plans for the benet of the same beneciary are
limited to one every 12 months.
$
, .
Amount (estimated)
D. Indirect rollover from another qualied 529 plan, an education savings account (ESA), or a qualied U.S. savings
bond.
• Indirect rollover from another qualied 529 plan or an ESA. Enclose documentation from the distributing nancial
institution detailing a breakdown of contributions and earnings.
• Indirect rollover from a qualied U.S. savings bond. Attach a statement or IRS Form 1099-INT issued by the distributing
nancial institution that shows the interest paid upon redemption.
If you do not provide this documentation, the entire amount will be considered earnings, which could result in
adverse tax consequences, particularly if you make a nonqualied withdrawal from your PA 529 Investment
Plan account.
$
, .
$
, .
Contributions Earnings
5
ES_PAD_EN_022621 — Page 5 of 8
7.
Subsequent Contributions (optional)
Important: These options can be established only on accounts held by a U.S. bank, savings and loan association, or credit union that
is a member of the Automated Clearing House (ACH) network. Money market mutual funds and cash management accounts offered
through nonbank nancial companies cannot be used.
Contributions by automatic investment plan or EBT will not be available for withdrawal for ve calendar days.
A. Automatic investment plan (AIP). Have a set amount electronically transferred from your bank account to your PA 529
Investment Plan account on a schedule.
• You may establish this service or change the debit amount and frequency at any time by visiting our website or calling us.
• Your PA 529 Investment Plan account will be credited one business day before the withdrawal from your bank account.
• To set this up, you must provide your bank information in Section 8.
Amount of Debit ($10 minimum):
00
$
, .
Frequency (Check one.): Monthly Quarterly
Start Date:
Date (mm-dd-yyyy)
Your bank account will be debited on the 20th of any month, unless you pick a different date.
Your bank account will be debited (money will be withdrawn) on the date you select, and your investment will be
credited (money will be added) to your PA 529 Investment Plan account on the previous business day. Note: AIPs
with a debit date of January 1st, 2nd, 3rd, or 4th will be credited in the same year as the debit date.
B. Payroll deduction. If you want to make contributions to your PA 529 Investment Plan account directly as a payroll deduction,
you must contact your employer’s payroll ofce to verify that you can participate. Payroll deduction contributions will not
be made to your PA 529 Investment Plan account until you have received a payroll deduction conrmation from the PA 529
Investment Plan, provided your signature and Social Security number or other taxpayer ID number on the form, and submitted
the form to your employer’s payroll ofce. The amount you indicate below will be in addition to payroll deductions that you may
have previously established on other PA 529 Investment Plan accounts.
$
, .
Amount of Deduction Each Pay Period ($10 minimum)
6
ES_PAD_EN_022621 — Page 6 of 8
8.
Bank Information (required to establish the AIP or EBT option)
Important: I acknowledge that my bank or nancial institution is located in the U.S. and/or adheres to U.S. banking regulations.
Important: The AIP option can be used only with accounts held by a U.S. bank, savings and loan association, or credit union that is a
member of the ACH network. Money market mutual funds and cash management accounts offered through nonbank nancial companies
cannot be used.
Name of Bank Account Owner (rst, middle initial, last)
Bank Name
Account Type:
Bank Routing Number Bank Account Number (Check one.) Checking Savings
Note: The routing number is located in the bottom left corner of your checks. You can also ask your bank for the routing number.
You must obtain a signature guarantee for the bank account owner if the bank account owner in this section and the 529 account owner
in Section 2 are not the same. A signature guarantee is not necessary if the bank account is a joint account and the 529 account owner
in Section 2 is one of the owners of the joint account.
Signature—BANK ACCOUNT OWNER MUST SIGN IF DIFFERENT FROM 529 ACCOUNT OWNER
Do not sign below until you are in the presence of the authorized ofcer of a bank, broker, or other qualied nancial
institution. A notary public cannot provide a signature guarantee, nor can you guarantee your own signature. Please
note that the PA 529 Account Owner will have access to the bank account information entered above.
SIGNATURE
Signature of Bank Account Owner
Date (mm-dd-yyyy)
Signature Guarantee
Signature of Bank Account Owner
Title
Name of Institution
Date (mm-dd-yyyy)
Authorized Ofcer to Place Stamp Here
9.
SAGE Scholars (Optional)
You may opt to participate, at no cost, in the SAGE Scholars Tuition Rewards Program through which you can earn tuition discounts at
colleges that participate in SAGE. The discount earned is 2.5% of the value of your GSP Account if used for higher education expenses.
Each SAGE participating school determines the maximum discount that it will honor, which is currently between $7,188 and $61,190
(spread evenly over four years of college.)
Your beneciary is eligible to enroll in the SAGE Scholars Program until he or she is 16 years old.
By enrolling you will receive $500 in SAGE Scholars Tuition Rewards discounts. Visit www.tuitionrewards.com to learn more.
Before you can use earned Tuition Rewards you must register at www.tuitionrewards.com.
I wish to enroll in the SAGE Scholars Program
7
ES_PAD_EN_022621 — Page 7 of 8
10.
Authorized Agent (Optional) (This individual will be able to obtain information about your account(s), and re-
ceive duplicate account statements from the Pennsylvania 529 Investment Plan.)
• If you wish to allow greater access, including such things as making changes to the account and authorizing withdrawals (authorized
agents, Levels 2-4), you must complete a Limited Power of Attorney/Agent Authorization form or Power of Attorney form,
available at PA529.com.
Note: If your agent is a corporation or other entity, the entity must also complete and submit a Pennsylvania College Savings
Program—529 Investment Plan Organization Resolution Form.
Name of Agent (Individual, corporation, or other entity)
Social Security Number or Individual Taxpayer Identication Number (EIN if it is an organization)
Address
City State Zip Code
Best Daytime Contact Number Additional Contact Number (Optional)
Relationship to Account Owner: Spouse Advisor
Other. If other provide relationship:
11.
Additional Information (Optional)
How did you hear about the PA 529 Investment Plan? (Check one.)
Direct mail Newspaper/magazine article
E-mail Online ad
Employer Radio ad
Event TV
Friend or relative Upromise website
Magazine ad
8
ES_PAD_EN_022621 — Page 8 of 8
12.
Authorization—YOU MUST SIGN BELOW
By signing below, I hereby apply for an account in the PA 529 Investment Plan. I certify that:
• I have received the PA 529 Investment Plan Disclosure Statement and Participation Agreement. I understand that by signing this
Enrollment Application, I am also signing and agreeing to be bound by the terms and conditions of the Disclosure Statement and
Participation Agreement. I understand that this Enrollment Application shall be construed, governed, and interpreted in accordance
with the laws of the Commonwealth of Pennsylvania.
• Except as set forth below, I understand that the Disclosure Statement and Participation Agreement constitutes the entire agreement
between the account owner and the PA 529 Investment Plan. No person is authorized to make an oral modication to this agreement.
• I understand that I may incur federal and state income and penalty taxes as a consequence of certain activities, including terminating my
account or changing my beneciary to an ineligible person. (Account owners should seek advice from a qualied tax advisor.)
• I understand that contributions to the PA 529 Investment Plan are not insured and that the investment returns are not guaranteed by
the Federal Deposit Insurance Corporation; The Vanguard Group, Inc.; Ascensus College Savings Recordkeeping Services LLC., or their
afliates; the Commonwealth of Pennsylvania; or any other government or government agency. I understand that contributions will be
invested under the direction of the Treasurer of State and there is no assurance that the accounts under the PA 529 Investment Plan will
generate any specic rate of return; in fact, there is no assurance that the accounts will not decrease in value.
• If I have chosen the AIP or EBT option, I authorize the Investment Plan and Ascensus College Savings Recordkeeping Services, LLC,
upon telephone or online request, to pay amounts representing redemptions made by me, or to secure payment of amounts invested
by me, by initiating credit or debit entries to my account at the bank named in Section 8. I authorize the bank to accept any such
credits or debits to my account without responsibility for their correctness. I acknowledge that the origination of ACH transactions
involving my account must comply with U.S. law. I further agree that the Investment Plan; Ascensus College Savings Recordkeeping
Services, LLC; The Vanguard Group, Inc.; and their respective afliates, will not incur any loss, liability, cost, or expense for acting
upon my telephone or online request. I understand that this authorization may be terminated by me at any time by notifying the
Investment Plan; Ascensus College Savings Recordkeeping Services, LLC; and the bank, and that the termination request will be
effective as soon as the PA 529 Investment Plan and Ascensus College Savings Recordkeeping Services, LLC, have had a reasonable
amount of time to act upon it. I certify that I have authority to transact on the bank account identied by me.
• If I have indicated that I wish to enroll in the SAGE Scholars Tuition Rewards Program by completing Section 9 and submitting this
enrollment form, I am authorizing and directing the PA 529 Investment Plan to provide SAGE Scholars, Inc., with my name, address,
and Social Security number and my beneciary’s name, address, and Social Security number, as well as my e-mail address and
information on the amount of SAGE Scholars Tuition Rewards discounts to which I am entitled. SAGE Scholars, Inc., will use this
information to administer the SAGE Scholars Tuition Rewards Program and may provide my information to SAGE Scholars member
schools so that they may contact me or my beneciary.
• I agree to the terms of the predispute arbitration clause as described in the Arbitration section of the Disclosure Statement and
Participation Agreement.
• I certify that the information provided on this form is true and accurate and that I am bound by the terms, rights, and responsibilities stated in
this agreement and by any and all statutory, administrative, and operating procedures that govern the PA 529 Investment Plan.
SIGNATURE
Signature of Account Owner Date (mm/dd/yyyy)
A valuable opportunity to supplement your college savings
Add to your college savings with the voluntary Upromise® service. Earn college savings from your
everyday eligible purchases like online shopping, dining out, traveling, and more. This service costs
nothing to join and when you link your Upromise and Pennsylvania 529 Investments Plan Accounts,
your earnings will be automatically transferred on a periodic basis ($25 minimum). Millions of families around the country already
take advantage of Upromise; join them!*
Here’s how to become a member of the Upromise service. After we’ve received your completed Enrollment Form, we’ll send you
a welcome letter that includes your Account number. Using this information, simply visit www.PA529.com to register for Web
access to your Account, then follow the online instructions to join Upromise. It’s that easy.
Already a Upromise member? Log in to your account and link it with your new Pennsylvania 529 Investment Plan Account number.
* Upromise is an optional service offered by Upromise, Inc., is separate from the Pennsylvania 529 Investment Plan and is not
afliated with the State of Pennsylvania. Transfers from Upromise to a Pennsylvania 529 Investment Plan Account subject to a
$25 minimum. Terms and conditions apply to the Upromise service. Participating companies, contribution levels and terms and
conditions are subject to change at any time without notice. Go to Upromise.com to learn more.
Upromise and the Upromise logo are registered service marks of Upromise, Inc. All other marks are the exclusive property of their
respective owners.
© 2021 Commonwealth of Pennsylvania.
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Enrollment Application

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Completed 23 September 2021

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