CSSF_05390L 0518 — Page 4 of 4
DO NOT STAPLE
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-Qualied 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-Qualied Withdrawals due to the death, disability, or scholarship
awarded to the Beneciary (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-Qualied 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 Beneciary.
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 certication that your signature is genuine.
• You can obtain a Medallion Signature Guarantee from an authorized ofcer of a bank, broker, or other qualied 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 ofcer 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 of Account Owner
Name of Institution
Authorized Ofcer 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 afliates.