4.
Payment Instructions (continued from previous page)
B. Electronic Funds Transfer: (Check one)
To Account Owner’s Bank Account on File
Bank Name:
Bank Account Number:
To Account Owner’s Bank Account Not on File with Bright Start (complete below bank information)
• Please have your signature Medallion-guaranteed in Section 6.
Name(s) on Bank Account:
If this bank account is a joint account, please
list the 529 account owner.
Account Type: Checking Savings
• This bank account will be linked to
your Bright Start College Savings
Program Account for telephone and
website purchase and redemption/
withdrawal transactions.
Bank Name and Address
Memo
Date
:123456789: 34568:
1234Your Name
Sample
Dollars
Pay to
the order of
$
TAPE YOUR PREPRINTED
VOIDED CHECK OR SAVINGS
ACCOUNT DEPOSIT SLIP HERE.
NOTE: Distributions to a Beneficiary or Institution of Higher Education for the benefit of the Beneficiary will be reported
on IRS Form 1099-Q under the Social Security Number or Taxpayer Identification Number of the Beneficiary. All other
distributions will be reported under the Social Security Number or Taxpayer Identification Number of the Account Owner.
5.
Authorization
I understand that the tax treatment of a withdrawal needs to be coordinated with the American Opportunity and
Lifetime Learning Credits, the Tuition and Fees Deduction, Coverdell Education Savings Account distributions, and
all other education related benefits. For specific tax guidance, I will consult with my tax professional.
By signing this form, I certify that I am the Account Owner of the Account indicated in Section I and that the information
contained on this withdrawal form is true, complete, and correct. I authorize the Program Manager to make this
distribution from my Account as indicated. I assume sole responsibility for the tax consequences of the above election
and understand that the earnings portion of a Non-Qualified Withdrawal is subject to federal and state income tax, as
well as an additional 10% federal penalty tax, and the recapture of any previous Illinois tax deductions taken for the
contribution portion of the withdrawal.
By selecting the electronic transfer service in Section 4, I acknowledge that the bank account in Section 4 will be linked
to my Bright Start Account, and I hereby authorize Union Bank & Trust Company to initiate debit and/or credit entries
to the bank account indicated above, and the bank indicated above to debit the same amount. I acknowledge that the
referenced bank account will be linked to my Bright Start College Savings Program Account so that I may purchase or
sell shares by telephone or online at BrightStartSavings.com. This authority is to remain in full force and effect until Union
Bank & Trust Company has received notification from me of its modification or termination in such time as to afford
Union Bank & Trust Company reasonable time to act on it. I understand that if a transaction cannot be made because
of insufficient funds or because either account has been closed, this service will be cancelled by Union Bank & Trust
Company. I acknowledge that the origination of Automated Clearing House (“ACH”) transactions to my account must
comply with the provisions of applicable law. I further agree that if my draft is dishonored for any reason, with or without
cause, Union Bank & Trust Company will not bear any liability. Union Bank & Trust Company may correct any transaction
errors with a debit or credit to my financial institution account and/or my Bright Start College Savings Program Account.
(Please retain a copy of this authorization for your records.)
I understand that it is my responsibility to maintain accurate records as may be required by the IRS to substantiate
this distribution for tax purposes.
3
BrightStart.com
