Fillable Withdrawal Request Form (New York's 529 Advisor-Guided College Savings Program)

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Withdrawal Request Form (New York's 529 Advisor-Guided College Savings Program)

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New York’s 529 Advisor-Guided College Savings Program
Withdrawal Request Form
• Complete this form to request a full or partial qualified or non-qualified withdrawal from your New York’s 529 Advisor-Guided College
Savings Program (“Advisor-Guided Plan” or “the Plan”) Account. 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 a 10% federal
penalty tax as well as state and local income taxes. See the Advisor-Guided Disclosure Booklet and Tuition Savings Agreement (“Disclosure
Booklet”) for more information. Capitalized terms that are not defined in this form have the meaning given to them in the Disclosure Booklet.
Note: You can also request a withdrawal by telephone or online at www.ny529advisor.com.
• We are required to file IRS Form 1099-Q if you take a withdrawal from your Advisor-Guided Plan Account.
• A contribution must be invested with the Advisor-Guided Plan for a period of seven (7) business days prior to withdrawal.
• If the address to which you’ve requested the withdrawal be sent has changed, or if you have changed your banking information in the last
fifteen (15) calendar days, your withdrawal will be held until this waiting period has been satisfied. If you want the withdrawal released
prior to the expiration of the waiting period, a Medallion Signature Guarantee is required in Section 7.
• 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 below. Do not staple.
• Under New York State law, distributions used to pay for K-12 Tuition Expenses will be considered non-qualified withdrawals and will require
the recapture of any New York State tax benefits that have accrued on contributions.
Forms can be downloaded from our website at www.ny529advisor.com, or you can call us to order any form — or request assistance in
completing this form — at 1.800.774.2108 any business day from 8 a.m. to 7 p.m. Eastern time.
Return this form and any other required documents to:
New York’s 529 Advisor-Guided College Savings Program
P.O. Box 55498
Boston, MA 02205-5498
For overnight delivery or registered mail, send to:
New York’s 529 Advisor-Guided College Savings Program
95 Wells Avenue, Suite 155
Newton, MA 02459
1.
Account Owner information
Account Number Social Security Number or Taxpayer Identication Number
Name of Account Owner (rst, middle initial, last)
Telephone Number (In case we have a question about your Account.)
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2.
Beneciary information
Name of Beneciary (rst, middle initial, last)
Social Security Number or Taxpayer Identication Number
Mailing Address (Required if payable/sent to Beneciary)
City State Zip Code
3.
Reason for withdrawal (Choose only one of the following seven options.)
A. Qualified withdrawal to the Account Owner.* My withdrawal will be used to pay for the Beneciary’s Qualied Higher
Education Expenses. (You will receive a check at your address unless you designate an alternate mailing address or ACH in
Section 5. Withdrawal checks may be held up to 9 business days after a change to the Account Owner’s mailing address.)
B. 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 address you indicated in Section 2 unless you designate an alternate
mailing address in Section 5. Withdrawal checks may be held up to fifteen (15) calendar days after a change to the Account
Owner’s mailing address.)
C. Qualified withdrawal to an eligible college or university.* My withdrawal will be sent to the school, either directly to the
address provided below or through HESC (Higher Education Services Corporation).
Mail check to school (If selecting Priority delivery in Section 5, please provide a street address and not a P.O. Box)
Name of School (Complete only if the withdrawal is to be sent directly to the school.)
Department/Ofce/Contact Name
Student ID
Mailing Address
City State Zip Code
OR
Pay through HESC (Higher Education Services Corporation): the Federal School Code can be located at FAFSA.ed.gov
Note: Allow up to 3 weeks for processing and delivery.
Name of School
Federal School Code Campus Code
* The IRS may require you to substantiate that your withdrawal is qualied. Consult the IRS or your tax professional for current documentation requirements.
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3. Reason for withdrawal (continued)
D. 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 unless you designate an alternate mailing address or ACH in Section 5.)
E. 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 or K-12 Tuition Expenses. (You will receive a check at your address of record unless you designate
an alternate mailing address or ACH in Section 5).
F. Non-qualified withdrawal to the Beneficiary.** My withdrawal will not be used to pay for the Beneciary’s Qualied
Higher Education Expenses or K-12 Tuition Expenses. (The Beneficiary will receive a check at the address you indicated in
Section 2 unless you designate an alternate mailing address in Section 5.)
G. Distribution for K-12 Tuition Expenses. Please note: Federal law allows distributions of up to $10,000 per Beneciary per
year for tuition expenses in connection with enrollment or attendance at an elementary or secondary public, private, or religious
school with no resulting federal taxes or penalties. However, under New York State law, distributions used to pay these expenses
will be considered non-qualied withdrawals and will require the recapture of any New York State tax benets that have accrued on
contributions. Please consult with a qualied tax or investment professional about your personal circumstances.
4.
Amount of withdrawal (Choose one.)
A. Full balance. Withdraw the entire amount held in all of the Investment Options in my Account, discontinue my Recurring
Contributions (if applicable), and close this Account. If I contribute to the Account by Payroll Direct Deposit, I must notify my
payroll department of the change.
B. Partial amount prorated from all Investment Options in your account. Provide the total amount of your withdrawal
below. We will withdraw that amount proportionately from all Investment Options you own.
$
, .
Total withdrawal amount
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.
Name of Investment Option Dollar amount OR Total balance
(For partial amounts.) (Check if applicable.)
$
, .
$
, .
$
, .
$
, .
$
, .
$
, .
$
, .
** Non-qualied withdrawals include those made because the Beneciary has become disabled, received a scholarship, or died.
Note: Earnings on non-qualied withdrawals are subject to federal income tax and may be subject to a 10% federal penalty tax,
as well as state and local taxes. For more information, refer to the Disclosure Booklet.
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5.
Delivery Method (Choose only one of the following.)
A. First-class mail. Check will be mailed via USPS. Allow up to 10 business days for delivery.
B. Priority delivery. Not available for P.O. boxes or non-street addresses.
A transaction charge of $15 will be applied to your Account.
Your distribution check should be received within three (3) business days of your trade date (no Saturday or holiday delivery).
Priority delivery is not available for HESC payments. Allow up to 3 weeks for payments to the school by HESC.
C. By Automated Clearing House (ACH) to Bank Account of Account Owner.
Important: If bank information has previously been added to your Account, it may take two (2) to ve (5) business days for the
proceeds of the withdrawal to transmit to your bank account. If you are providing bank information below, or if you have added
bank information within the last fteen (15) calendar days, your withdrawal will be held until this waiting period has been
satised. To waive this holding period, a Medallion Signature Guarantee is required in Section 7. To establish bank
services now, ll out the information below:
Bank information. ACH can only be made through accounts held by a U.S. Bank, savings and loan association, or credit
union that is a member of the Automated Clearing House (ACH) network. Money market mutual funds and cash management
accounts offered through non-bank nancial companies cannot be used.
Important: By signing this paperwork, you agree and conrm that your ACH transactions will not involve a bank or other nancial
services company, including any branch or ofce thereof, located outside the territorial jurisdiction of the United States.
Bank Name
Bank Registration (Name on bank account)
Account Type (Check One):
Bank Routing Number Bank Account Number Checking Savings
Note: The routing number is usually located on the bottom left corner of your checks. You can also ask your bank for the routing number.
D. Account Owner or Beneficiary Alternate Mailing Address. A Medallion Signature Guarantee in Section 7
is required for this option.
Mailing Address
City State Zip Code
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6.
Signature — YOU MUST SIGN BELOW
IMPORTANT: If you require a Medallion Signature Guarantee, do not sign in this section; see Section 7.
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 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 modication 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-qualied withdrawals, terminating my Account, or changing my Beneciary to an ineligible person. Account
Owners should seek advice from a qualied 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 afliates, J.P. Morgan Distribution Services, Inc., or the investment managers for the underlying funds in the
Plan. There is no assurance that my Account will generate any specic 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 Qualied Tuition Program offered by the State of New York on behalf of the Beneciary 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 the Investment Options offered by the Plan have been designed to save for post-secondary higher education
expenses and that for New York State tax purposes, the earnings on a withdrawal used to pay K-12 Tuition Expenses will be
considered a non-qualied withdrawal and will require the recapture of any New York State tax benets that have accrued
on contributions.
• all the information that I provided on this form is true and accurate in all material respects, that Ascensus Investment Advisors, LLC
and its afliates 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)
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7.
Medallion Signature Guarantee - REQUIRED FOR WAIVING OF HOLDING PERIOD FOR NEW BANKING
INFORMATION OR THE USE OF AN ALTERNATE MAILING ADDRESS
• You must provide the following information as underwritten certication that the signature is genuine.
• You can obtain a Medallion Signature Guarantee from an authorized ofcer of a bank, broker, or other 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.
By signing this form I agree to all of the certications, terms and conditions set forth above in Section 6.
SIGNATURE
Signature of Account Owner
SIGNATURE
Signature of Guarantor
Title
Name of Institution
Date (mm/dd/yyyy)
B-022044-1 (0720)
Authorized Ofcer to place stamp here
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Withdrawal Request Form (New York's 529 Advisor-Guided College Savings Program)

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