Transcription of CONTRIBUTION AND INVESTMENT SELECTION
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CONTRIBUTION AND INVESTMENT SELECTION
Page 1 of 25107 / 2514E (Rev. 10/ 2014 ) 2018 Ascensus, LLCCONTRIBUTION AND INVESTMENT SELECTIONPART 1. DESIGNATED BENEFICIARYName (First/MI/Last) _____Social Security Number _____Date of Birth _____Account Number_____ Suffix _____PART 2. COVERDELL ESA TRUSTEE OR CUSTODIANTo be completed by the Coverdell ESA trustee or custodianName _____Address Line 1 _____Address Line 2 _____City/State/ZIP _____Phone _____ Organization Number _____PART 3. CONTRIBUTION INFORMATIONC ontribution Amount _____ CONTRIBUTION Date _____ CONTRIBUTION TYPE (Select one) 1. Regular CONTRIBUTION for Tax Year _____ 2. Rollover (Distribution from a Coverdell ESA that is being deposited into this Coverdell ESA) By selecting this transaction, I irrevocably designate this CONTRIBUTION as a rollover. 3. Transfer (Direct movement of assets from a Coverdell ESA into this Coverdell ESA)CONTRIBUTOR INFORMATIONName (First/MI/Last) _____ Phone _____PART 4.
Page 2 of 2 5107 / 2514E (Rev. 10/2014) ©2018 Ascensus, LLC RULES AND CONDITIONS APPLICABLE TO COVERDELL ESA CONTRIBUTIONS Coverdell ESA contribution …
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