ES_NYA_TC 072001 0820 — Page 3 of 4
DO NOT STAPLE
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4.
Signature — YOU MUST SIGN BELOW
By signing below, I hereby certify that:
• I authorize the Plan to contact the person listed in Section 3. above and disclose information about my Account to address possible
nancial exploitation, to conrm the specics of my current contact information, health status, or the identity of any legal guardian,
executor, trustee or holder of a power of attorney, or as otherwise permitted by FINRA Rule 2165. I certify that the Trusted Contact
Person is at least eighteen (18) years of age.
• I have received the Plan’s Disclosure Booklet and Tuition Savings Agreement (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 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 me 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. I
understand that it is my responsibility to 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, LLC, and its afliates, JP Morgan Distribution Services, Inc., or the investment managers for the underlying funds in the
Plan. There is no assurance that my Accounts in 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 understand that by signing this form, I authorize Ascensus Broker Dealer Services, LLC or its afliates to provide my Trusted
Contact Person with information regarding my Account. I agree to indemnify, defend, and hold harmless the Plan, the State of New
York, its agencies, or any other government or government agencies, Ascensus Broker Dealer Services, LLC, JP Morgan Distributors,
Inc., the investment managers for the underlying funds in the Plan, and their respective afliates, agents, and employers, from any
losses I incur as a result of the acts or omissions of my Trusted Contact Person.
• All the information that I provided on this form is true and accurate in all material respects. Ascensus Broker Dealer Services, LLC
and its afliates are entitled to rely on the information provided herein and the instructions provided on this form. 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)
INFOCHANGE 0720
