4
Allocation Instructions (You must complete all applicable parts of this section.)
Tell the Program where to deposit your contributions.
Use only one form to contribute to all Account(s) for all Beneficiaries. Attach an additional sheet of paper, if needed.
Allocation instructions you provide in this section apply to your payroll deduction contributions only – not to future contributions you may
make to this account by check, automatic contribution plan, or any method except payroll deduction contributions.
Beneficiary Name
(Provide first and last name.)
Investment Options
(See list below.)
Is this a
new Option?
Percentage of each
contribution
1.
Yes or No . 0 0
%
2.
Yes or No . 0 0
%
3.
Yes or No
. 0 0
%
4.
Yes or No . 0 0
%
Total Allocation Per Pay Period
10 0 . 00
%
5
Employee Authorization and Signature (You must sign exactly as your Account is registered.)
By signing below, I authorize my employer to process periodic deductions from my paycheck for contribution into my Michigan
Education Savings Program Account(s). I acknowledge and agree that my remedy for any errors made in connection with these
transactions is limited to simple reimbursement of the amount of the error. I authorize the Program and its agents to make adjustments
to my Account(s) to correct such error.
I understand that my Program Account(s) may not be credited with my payroll deduction until the funds are received from my employer
and that the date on my payroll stub may not be the same date the deposit is credited to my Account(s). This authorization will remain in
effect until cancelled by me or by the Program, or upon termination of my employment with my employer.
Employee Signature (The employee must be the Account Owner or the Custodian for a Minor.) Date
Employee Checklist
This checklist has been developed to help employees establish payroll deduction for their Program Account(s). Please read it carefully before
completing this form.
Be sure to include your Social Security Number or Taxpayer Identification Number on this form. That’s how your payroll deduction is
remitted to the Program for deposit into your Account(s).
Use one form to allocate your payroll deduction into your Program Account(s) for one or more Beneficiaries. You may use an additional
sheet of paper, if needed, as long as the total allocation for all accounts equals 100%. Your payroll deduction form will be rejected in its
entirety if the any allocation is not a whole percentage or if any allocation results in a contribution amount of less than $15 for any
Investment Option (for any Beneficiary).
Refer to the Disclosure Booklet, then select from one or more of the following Investment Options for each Account you own:
Investment Option Names
Conservative Age Based Allocation Option
Moderate Age Based Allocation Option
Aggressive Age Based Allocation Option
Global Equity Index Option (1933)
Principal Plus Interest Option (1934)
Balanced Option (2190)
100% Fixed Income Option (2191)
U.S. Equity Index Option (2337)
International Equity Index Option (2338)
The employee must be the Account Owner on all Program Account(s). You cannot contribute payroll deductions into an Account owned
by your spouse, or by anyone else. It may take up to 10 days from the receipt of this form before a payroll deduction can be accepted.
Contact your employer to change the amount or to stop payroll deduction. Contact the Program to change the allocation only.
Employer Checklist
The following information has been developed to help you establish automatic payroll deduction for any employee. Please read it carefully
before sending funds to the Program on behalf of any employee via ACH (Automated Clearing House) funds.
Code the account as “checking” and transmit ACH funds to State Street Bank. Use State Street’s ABA number: 011000028.
Enter the account number, a 17-digit field, as follows. Do not use any spaces or dashes. The first 8 digits identify the Program. Use the
Program’s DDA number: 99055121.The next 9 digits identify the Employee. Use the Employee’s Social Security or Taxpayer Identification
Number. It may take up to 10 days from the receipt of this form before a payroll deduction can be accepted.
Questions? Visit www.MIsaves.com or call toll-free 1-877-861-MESP.
Mail this form to:
Michigan Education Savings Program
PO Box 55925
Boston, MA 02205-5925
.
A12314:10/2015
