Florida Prepaid College Plan Refund Release …

1 Florida Prepaid College plan Refund Release Request Form Thi s form may be used to Release a Refund that h as been pl aced on hold . Th is f orm may n ot be use d to canc el an a ccou nt . If you wo uld like to cancel your accou nt, please download a C ance llati on F orm, fou nd at s. A re que st for a refun d th at has been plac ed on hold requires the acc ou nt o wn er s notarized si gn ature . T he survi vor s notarized sign ature is also required for pla ns purchas ed on or after February 1, 2009 that includ e coverag e for Reg istration Fe es, along with any associated su pplemental plan (s). For more information, see the Master Contract at .com. Th e Refund w ill be mailed to the address on file.

2 If an update is requ ired, a Change of Ad dres s F orm may be d ow nl oaded fro m om/ form s. T he account ow ne r s signature is requ ired to chan ge the addres s on an ac cou nt. In order for the address update to b e made w ith the Refund Release , t he Ch ang e of Ad dre ss form must a ccompany this n otarized form. Re funds are made payable only to the account owner and are usually mailed within 45 days. An incomplete or i ncorre ctly com plete d form may delay the refu nd rel ea se proc ess. Please r emembe r: All signa tur es must be original and notarized. Fa xe d or p hotocopied notarized s ign atures will not be ac cepted. The notary must properly sign the form. The notary must da te the f orm. The notary must print the names of the acc ount owner and survivo r (if applicable) in t he appropriate s ecti on.

3 A se parate notary stamp is required for each sig nature even if the same indi vidual notariz es both signatures. All signa tures must be individually acknowledge d by a nota ry. If yo u hav e an y q uestions or concerns, pleas e c all 1-800-552-GRAD (4723) and press prompt 2. Florida Prepaid College plan Refund Release Request Form Customer I nform ation: Na me of A ccount Owner or A utho rize d Repre sen tativ e of B usiness/O rgani zati on/ Tru st (_ ) - - Dayt ime Telephone Number plan Number Name of B eneficia ry (Student) Plea se r eturn the comp leted and notarized form to: Flor ida Prepaid College Boa rd, P O Box 6567, Tal lahasse e, FL 32314-6567 I (We) author ize the Flori da Pre paid College Boa rd to Release the r efu nd for the above-referenced plan (s).

4 ACCOUNT OWNER SURVIVOR X ACCOUNT OWNER S S IGN ATUR E R EQUIR ED State of , County of X SURVIVOR S SIGNATURE-REQUIRED F or plan s purchased on or a fte r February 1, 200 9 that i ncl ude coverage for R egistration Fees, along with any associ ated supplemental plan ( s). State of , County of The foregoing instrument was acknowledged before me This day of , 20 The foregoing instrument was acknowledged before me This day of , 20 by (PRINT ACCOUNT OWNER S NAME) who (select one): is personally known, OR produced identification Ty pe of Identi ficati on: by (PRINT SURVIVOR S NAME) who (select one): is personally known, OR produced identification Ty pe of Identi ficati on: State of: State of: X SIGNATUR E OF NOTAR Y R EQUIR ED X SIGNATUR E OF NOTAR Y R EQUIR ED Nota ry Sta mp Nota ry Sta mp