ES_NYA_PDD 072001 0820 — Page 2 of 2
DO NOT STAPLE
2
2.
Payroll Direct Deposit instructions
Note: Contributions by Payroll Direct Deposit must total a minimum of $25.00 per month
Check One:
Add Payroll Direct Deposit
Change Amount
Delete Payroll Direct Deposit (Skip to Section 3)
Deduct
00
$
, .
from my paycheck each pay period and allocate the amount among my Advisor-Guided Plan
Account(s) as detailed in Section 1 ($25 minimum per Account per month):
Important: Check here if you are an employee of the State of New York.
State Agency/Department
3.
Signature — YOU MUST SIGN BELOW
By signing below, I hereby certify that:
• I have received the Disclosure Booklet and Tuition Savings Agreement of New York’s 529 Advisor-Guided College Savings Program
(“Disclosure Booklet”). I understand that by signing this form, I am agreeing to be bound by the terms and conditions of the Disclosure
Booklet. I understand that the New York’s 529 Advisor-Guided College Savings Program (“Plan”) may from time to time amend the
Disclosure Booklet, and I agree I will be subject to the terms of those amendments. I understand that the Disclosure Booklet and this
form shall be construed, governed, and interpreted in accordance with the laws of the State of New York.
• I understand that the Disclosure Booklet and the Plan forms signed by me constitute the entire agreement between the Account Owner
and the Plan. No person is authorized to make an oral modication to this agreement.
• I understand that I may incur federal, state or local income and penalty taxes as a consequence of certain activities, including without
limitation non-qualied withdrawals, terminating my Account, or changing my Beneciary to an ineligible person. Account Owners
should seek advice from a qualied tax professional.
• I understand that contributions to the Plan are not insured and that the investment returns are not guaranteed by the Federal Deposit
Insurance Corporation, the State of New York, its agencies, or any other government or government agency, Ascensus Broker Dealer
Services, Inc., and its afliates, JP Morgan Distribution Services, Inc., or the investment managers for the underlying funds in the Plan.
There is no assurance that the accounts under the Plan will generate any specic rate of return; and there is no assurance that the
Account will not decrease in value. I understand that I could lose money.
• I understand that contributions that cause the total balance of this Account and any other Accounts established in the Plan and in
any other Qualied Tuition Program offered by the State of New York on behalf of the Beneciary to exceed the Maximum Account
Balance set forth in the Disclosure Booklet are not permitted. I understand that if a contribution is made to my Account that exceeds the
Maximum Account Balance, all or a portion of the contribution amount will be returned to me or the contributor.
• I certify that all the information that I provided on this form is true and accurate in all material respects, that Ascensus Investment
Advisors LLC and its afliates are entitled to rely on the information provided herein and the instructions provided on this form, and that
I am bound by any and all statutory, administrative, and operating procedures that govern the Plan.
SIGNATURE
Signature of Account Owner Date (mm/dd/yyyy)
529-F-PDD 0720
