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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ciarys 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ciarys 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.
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