my529.org | 800.418.2551 Page 1 of 1
The term my529 is a registered service mark. . Form 110 | February 2018
Form 110
Account Owner/Agent Signature Card
ABOUT THIS FORM
• This form is used to secure the signature of an account owner who opens an account online.
• Please complete this form in its entirety. The information and signature you provide below will be used to validate current and future account
transactions such as withdrawals, internal transfers, and account information changes.
• Only one Account Owner/Agent Signature Card per account owner is required to be submitted to my529.
• Failure to complete and submit this document may delay future account transactions.
SUBMITTING THIS FORM
• Please print clearly—preferably in capital letters, using black or blue ink.
• To ask questions about completing this form, contact my529 toll-free at 800.418.2551 on business days from 7 a.m. to 6 p.m. MT.
• Return this form to: my529, PO Box 145100, Salt Lake City, UT 84114-5100. For delivery by overnight carrier, send to: my529, Board of Regents
Building, Gateway 2, 60 South 400 West, Salt Lake City, UT 84101-1284. You may also fax this form to 800.214.2956.
Account Owner/Agent Information
1
Signature Authorization
3
Account Owner/Agent’s U.S. Social Security Number (Required) OR TaxpayerIdenticationNumber (Required)
Account Owner/Agent’s Last Name First Name Middle Name
By signing below,
• I certify that I have received, read, understand, and agree to all the terms and conditions in the Program Description and Account Agreement as
presented when I opened my account online.
• Iunderstandthemy529requiresmyname,U.S.SocialSecurityorTaxpayerIdenticationNumber,andsignatureinordertoverifymyidentity.
• I certify that the information provided on this form is true and accurate.
Title (if signed on behalf of a trust, corporation, or other institution)
Account Owner/Agent Signature
Account Owner/Agent Name (please print)
Date (mm/dd/yyyy)
Required
For my529 Use Only
my529 ID No.
Date Received by my529
User Initials
my529AccountNumber Beneciary’sLastName FirstName
my529AccountNumber Beneciary’sLastName FirstName
my529AccountNumber Beneciary’sLastName FirstName
my529AccountNumber Beneciary’sLastName FirstName
If the number of beneficiaries exceeds the space available, attach a separate page showing the information requested in this section for the additional beneficiaries.
my529 Account Information
2
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