Signature and Authorization. Required The undersigned certifies that the undersigned has established a successor BARON FUNDS® Xxxxxxxxx Education Savings Custodial Account meeting the requirements of Internal Revenue Code Section 530(b) to which assets will be transferred, that the Xxxxxxxxx ESA from which assets are being transferred meets the requirements of Internal Revenue Code Section 530(b) and that the transfer satisfies the requirement for a nontaxable transaction. Signature of Student/Adult (Please circle one of the above) Special Note: If Student is a minor under the law of Student’s state of residence, the Adult must execute this Xxxxxxxxx Education Savings Account Transfer Form.
Signature and Authorization. The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding. I understand that all changes are subject to the terms of my annuity contract and acceptance by the Company and that upon acceptance, changes become part of my annuity contract. I understand that the Company and its representatives cannot give legal, tax, or accounting advice and that I am solely responsible for all tax obligations arising from this transaction and for compliance with all applicable laws and regulations. Under penalties of perjury, I certify that the number shown on this Service Request is my correct taxpayer identification number (or I am waiting for a number to be issued to me). Note: If the owner resides in a Community Property State, which could be subject to change, (currently AK, AZ, CA, ID, LA, NM, NV, TX, WI or WA), the owner’s spouse must also sign the Systematic Withdrawal Form. Unless the Insurance Company has been notified of a community or marital property interest in this contract, the Insurance Company will rely on its good faith belief that no such interest exists and will assume no responsibility for inquiry. Signature of Owner or Legal Representative: Date: Signature of Joint Owner (If Applicable): Date: Spouse Signature (If Applicable): Date: If your address information has changed with EquiTrust in the last 30 days, then this form must be signed in the presence of a Notary Public. Please complete the Service Request form for the address change information. The Notary Public must witness and sign below. State of ) ) SS. County of ) On this day of , 20 , before me, the undersigned, a Notary Public in and for the State of , personally appeared , to me known to be the person named in and who executed the foregoing Certification, and acknowledged that he/she executed the same as his/her voluntary act and deed. Notary Public* Signature *Note: Per EquiTrust Life Insurance Company Business Guidelines, agents may not act as notary on client’s financial transactions. (Affix Notary's Stamp or Seal Here) My commission expires EquiTrust Life Insurance Company • P.O. Box 14500 • Des Moines, IA 00000-0000 Phone 000-000-0000 • Fax 000-000-0000 AUTOMATIC DEPOSIT AUTHORIZATION AGREEMENT Owner/Joint Owner: Contract Number (if known): Contract type: Deferred Annuity Contract Single Premium Immediate Annuity NOTE: Amounts greater than $50,000 must be distributed via check.
Signature and Authorization. Required The undersigned certifies that the undersigned has established a successor ACCEPTANCE BY NEW CUSTODIAN UMB Bank, N.A. agrees to accept transfer of the above amount for deposit to the Student’s BARON FUNDS® Xxxxxxxxx Education Savings Custodial Account and requests the liquidation and transfer of assets as indicated above. BARON FUNDS® Xxxxxxxxx Education Savings Custodial Account meeting the requirements of Internal Revenue Code Section 530(b) to which assets will be transferred, that the Xxxxxxxxx ESA from which assets are being transferred meets the requirements of Internal Revenue Code Section 530(b) and that the transfer satisfies the requirement for a nontaxable transaction. Signature of Student/Adult (Please circle one of the above) Special Note: If Student is a minor under the law of Student’s state of residence, the Adult must execute this Xxxxxxxxx Education Savings Account Transfer Form. UMB Bank, N.A., Custodian Signature of Custodian
Signature and Authorization. I request and authorize ReliaStar Life Insurance Company to obtain payment amounts due the Company by debiting my account in the form of electronic debit entries. I also request and authorize the bank named above to accept and honor the same and to charge the same to my account. This Authorization will remain in effect until I notify the Company or bank (in writing) to terminate and they have a reasonable time to act on the termination. I hereby terminate any prior Authorization of the Company to this account, effective on the date the Company initiates the first electronic payment under this Authorization. I understand that I may stop payment of any charge by notifying the bank before my account is charged. This Authorization becomes effective when it is received in the Company’s service office. I acknowledge receipt of a copy of this Authorization on this date. Owner Signature (Required) Date
Signature and Authorization. Required confirmation of the purchase of the fund shares indicated above will serve as notification of State Street Bank and Trust Company’s acceptance of appointment as Custodian of the Owner’s Account. The account is established for the exclusive benefit of the individual or his/her beneficiaries. STATE STREET BANK AND TRUST COMPANY, CUSTODIAN Signature of Custodian If the Depositor is a minor under the laws of the Depositor’s state of residence, a parent or guardian must sign this Agreement. Until the Depositor reaches the age of majority, the parent or guardian will exercise the powers and duties of the Depositor. (If guardian, provide a copy of letters of appointment.) Under penalties of perjury, I certify that:
