Fill - Withdrawal Request Form

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State Farm

529 Savings Plan

Withdrawal Request Form

• Use this form to request a full or partial Qualified or Non-Qualified

Withdrawal from your State Farm 529 Savings Plan (State Farm Plan) Account

or an indirect rollover out. You must submit a separate form for each type

of withdrawal you are requesting. The earnings portion of Non-Qualified

Withdrawals from your Account may be subject to federal income tax and

an additional 10% federal tax and may be subject to state and local income

taxes. See the State Farm Plan Program Disclosure Statement and Participation

Agreement (Program Disclosure Statement) for more information.

Note: You can also request a Qualified Withdrawal by telephone or online at

www.statefarm529.com.

• We are required to file IRS Form 1099-Q if you take a withdrawal from your

State Farm Plan Account.

• A contribution must be invested with the State Farm Plan for a period of five (5)

business days prior to withdrawal.

• If the Account Owner or address on your Account has changed within the last ten

(10) business days, this Withdrawal Request Form must be Medallion Signature

Guaranteed in Section 5.

• Type in your information and print out the completed form, or print clearly,

preferably in capital letters and black ink. Mail the form to the address listed.

Do not staple.

Forms can be downloaded from our website at www.stat

efa

rm.com,

or you can call us to order any form — or request assistance in completing this

form — at 1.800.321.7520 any business day from 8 a.m. to 8 p.m. Central time.

1. Account information

Account Number Account Owner Social Security Number or Taxpayer Identication Number (Required)

Name of Account Owner (rst, middle initial, last)

Telephone Number (In case we have a question about your Account.)

Name of Beneciary (rst, middle initial, last)

Beneciary Social Security Number or Taxpayer Identication Number (Required)

Mailing Address

City State Zip Code

1.800.321.7520

8 a.m. to 8 p.m. Central Time M-F

www.statefarm.com

Regular mailing address:

State Farm 529 Savings Plan

P.O. Box 419096

Kansas City, MO 64141-9096

Overnight mailing address:

State Farm 529 Savings Plan

920 Main Street, Suite 900

Kansas City, MO 64105

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2. Reason for withdrawal (Choose only one of the following six options.)

A. Qualified Withdrawal to the Account Owner, Parent/Guardian or Custodian. My withdrawal will be used to pay for the

Beneciary’s Qualied Higher Education Expenses, as dened in the Program Disclosure Statement. (You will receive a check

at your address of record.)

B. Qualified Withdrawal to the Bank Account of the Account Owner, Parent/Guardian or Custodian. My withdrawal will

be used to pay for the Beneciary’s Qualied Higher Education Expenses, as dened in the Program Disclosure Statement. My

withdrawal should be sent via Electronic Fund Transfer (EFT) using banking instructions on le with the State Farm Plan. (You

cannot change or add banking instructions at the same time of the withdrawal request via EFT.)

C. Qualified Withdrawal to the Beneficiary. My withdrawal will be used to pay for the Beneciary’s Qualied Higher

Education Expenses. (The Beneficiary will receive a check at the Beneficiary’s address of record.)

D. Qualified Withdrawal to an eligible college or university. (Provide the exact school address below.)

Name of School (Complete only if the withdrawal is to be sent directly to the school.)

Department/Ofce/Contact Name

Beneciary’s Student ID

Mailing Address

City State Zip Code

E. Indirect rollover. I will invest my withdrawal in another qualied 529 plan within the next 60 days. (You will receive a check

at your address of record.)

F. Non-Qualified Withdrawal to the Account Owner. My withdrawal will not be used to pay for the Beneciary’s Qualied

Higher Education Expenses. (You will receive a check at your address of record.)

G. Non-Qualified Withdrawal to the Beneficiary. My withdrawal will not be used to pay for the Beneciary’s Qualied Higher

Education Expenses. (The Beneficiary will receive a check at the Beneficiary’s address of record.)

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3. Amount of withdrawal (Choose one.)

A. Full balance. Withdraw the entire amount held in all of the Investment Options in my Account, discontinue my Automatic

Investment Plan (AIP) (if applicable), and close this Account.

Important: If you contribute to your Account through Payroll Direct Deposit, you must notify your employer to cancel

these contributions.

B. Partial amount of

, .

Withdraw this amount proportionately from among my current Investment Options. If the amount you indicate exceeds the

amount available, State Farm 529 Savings Plan will liquidate the entire balance, discontinue your AIP, and close your Account.

C. Partial amount as follows.

Important: If the dollar amount you indicate for a particular Investment Option exceeds the amount available for withdrawal,

we will liquidate the entire balance of that Investment Option.

Dollar amount OR Total balance

Name of Investment Option (For partial amounts.) (Check if applicable.)

, .

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4. Signature — YOU MUST SIGN BELOW

• I certify that I have read, understand, consent, and agree to all terms and conditions of the Program Disclosure Statement and

understand the rules and regulations governing withdrawals from my State Farm Plan Account. I also certify that the information

provided on this form is accurate and hereby instruct the State Farm Plan to distribute my Account as I have indicated.

• By signing below, I authorize the Program Manager or its designees to withdraw funds according to the instructions above. I

understand that if I have changed my address or the Account Owner, I cannot withdraw funds within ten (10) business days of the

change without the Medallion Signature Guarantee.

• I understand that the earnings portion of Non-Qualied Withdrawals is subject to federal income tax and an additional 10% federal

tax, and may be subject to state income tax. I understand that Non-Qualied Withdrawals due to the death, disability, or scholarship

awarded to the Beneciary (up to the scholarship amount) may not be subject to an additional 10% federal tax. Further, I also understand

that I am responsible for reporting the withdrawal on my income tax returns for the tax year the Non-Qualied Withdrawal was made.

• I understand that if I had taken a state income tax deduction or credit on my state income taxes I will need to check with my home

state to determine if my deduction or credit is subject to recapture.

• If the Account is owned by an entity or trust, I certify that I am authorized to act on its behalf in making this request. If the Account

is Minor-Owned or is funded with UGMA/UTMA assets, I further certify that I am the Parent/Guardian/Custodian of the Account in

question, and that this request is in the best interest of the Beneciary.

SIGNATURE

Signature of Account Owner Date (mm/dd/yyyy)

If this form requires a Medallion Signature Guarantee, proceed to Section 5.

5. Medallion Signature Guarantee — REQUIRED IF ACCOUNT OWNER OR ADDRESS HAS CHANGED

WITHIN THE LAST 10 BUSINESS DAYS AND YOU WOULD LIKE TO WAIVE THE 10 BUSINESS DAY

HOLD PERIOD FOR THIS WITHDRAWAL REQUEST.

• You must provide the following information as underwritten certication that your signature is genuine.

• You can obtain a Medallion Signature Guarantee from an authorized ofcer of a bank, broker, or other qualied nancial institution.

A notary public cannot provide a Medallion Signature Guarantee, nor can you guarantee your own signature.

• Do not sign below until you are in the presence of the authorized ofcer providing the Medallion Signature Guarantee.

I certify that the information provided herein is true and complete in all respects, and that I have read and understand, consent,

and agree to all the terms and conditions of the Program Disclosure Statement.

SIGNATURE

Signature of Account Owner

Signature Guarantor

Title

Name of Institution

Date (mm/dd/yyyy)

Authorized Ofcer to place stamp here

Nebraska Educational Savings Plan Trust, Issuer. Nebraska State Treasurer, Trustee. Nebraska Investment Council, Investment Oversight. First

National Bank of Omaha, Program Manager. First National Capital Markets, Inc. Distributor, Member FINRA, SIPC, State Farm, Selling Dealer.

First National Capital Markets and First National Bank of Omaha are afliates.

Fill Online, Printable, Fillable, Blank Withdrawal Request Form Form

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Fillable Withdrawal Request Form

Fill Online, Printable, Fillable, Blank Withdrawal Request Form Form

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