529 College Savings Plan Trustee Certification of Investment Powers

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529 College Savings Plan Trustee Certification
of Investment Powers
Use this form to add or change Trustee information on your 529 Plan account. Please complete all
sections. This form must accompany a 529 Plan new account application when a Trust 529 Plan account is established.
Trust customers must attach copies of those pages of the Trust which provide the full name of the Trust and all signatures.
We will review and store only the portions of the Trust containing this requested information.
The Trustees authorized on this form will supersede any earlier designations. If you have any questions, please call us at
1-800-544-6666 or visit us at Fidelity.com/college.
Return the completed form to Fidelity Investments, P.O. Box 770001, Cincinnati, OH 45277-0002.
1
PARTICIPANT TRUST INFORMATION AND CERTIFICATION OF INVESTMENT POWERS
Trust Account Number
TIN or
Name of trust
SSN
Date of trust
Name of Grantor
Trust Permanent address
(no P.O. boxes or C/O)
Trust Mailing address
(if different from above)
2
Street
CityState
ZIP
Street
CityState
ZIP
TRUSTEES
2a. The undersigned certify that the Trust indicated in Section 1 has the following Trustees (attach an additional sheet of paper if necessary).
All fields in bold are required.
1st Trustee
Full legal name
Title
Permanent address
(no P.O. boxes)
Mailing address
(if different from above)
Street
City
StateZip
Street
City
StateZip
Date of birth (mm/dd/yyyy)
Social Security number
or Taxpayer ID Number
Phone numbers Evening
Daytime
Countries of citizenship
U.S.
Other(s)
UNEXPIRED GOVERNMENT ID
Ext.
Country of
tax residence
U.S.
Other
(FOREIGN CITIZENS ONLY)
Identification document must have a reference number and photo. Please attach a photocopy.­
Place of birth
City
Immigration status
State/Province
Permanent resident
Non-permanent resident
Country
Non-resident
Check which type of document you are providing: U.S. driver’s license
DHS permanent resident card
Passport with U.S. visa
Employment
Authorization Document (EAD)
Passport without U.S. visa
Foreign national identity document
Document number and country of issuance
(Number from the document checked above)
Page 1 of 8
1.772565.106002800301
2
TRUSTEES
(CONTINUED)
1st Trustee (continued)
Employment status
Employed
Not employed
Self-Employed and my employment
address is the same as my legal address
Retired
Self-Employed and I am providing
my employment address below
Occupation:
Employer’s name:
Employer’s address:
Street
City
StateZip
ASSOCIATIONS
Check this box if you are associated with, or employed by, a stock exchange or a member firm of an exchange or FINRA, a
municipal securities dealer, or Fidelity. If you checked the box, obtain and attach the compliance officer’s letter of
approval (“407 letter”) and indicate the name and address of the entity with which you are associated below. Failure to
include an approval letter may delay the processing of your request. We must tell the associated entity that you have
applied for this account.
Check here if your association is through your employer. (If you checked this box, you are not required to complete the
information below.)
Associated entity name
Address
City
State
ZIP
Control
Check this box if you are a control person associated with either (a) another member, (b) a member organization, or (c) an
immediate family/household member of a control person, or are associated with a publicly traded company under SEC
Rule 144 (this would include, but is not limited to, a director, 10% shareholder, policy-making officer, and members of
the board of directors).
Trading Symbol
Company Name
2nd Trustee
Full legal name
Permanent address
(no P.O. boxes)
Mailing address
(if different from above)
Title
Street
City
StateZip
Street
City
StateZip
Date of birth (mm/dd/yyyy)
Social Security number
Phone numbers Evening
Countries of citizenship
U.S.
Other(s)
UNEXPIRED GOVERNMENT ID
or Taxpayer ID Number
Daytime
Country of
tax residence
U.S.
Ext.
Other _________________
(FOREIGN CITIZENS ONLY)
Identification document must have a reference number and photo. Please attach a photocopy.­
Place of birth
City
Immigration status
State/Province
Permanent resident
Non-permanent resident
Country
Non-resident
Check which type of document you are providing: U.S. driver’s license
DHS permanent resident card
Passport with U.S. visa
Passport without U.S. visa
Foreign national identity document
Document number and country of issuance
(Number from the document checked above)
Page 2 of 8
Employment
Authorization Document (EAD)
2
TRUSTEES
(CONTINUED)
2nd Trustee (continued)
Employment status
Employed
Not employed
Self-Employed and my employment
address is the same as my legal address
Retired
Self-Employed and I am providing
my employment address below
Occupation:
Employer’s name:
Employer’s address:
Street
City
StateZip
ASSOCIATIONS
Check this box if you are associated with, or employed by, a stock exchange or a member firm of an exchange or FINRA, a
municipal securities dealer, or Fidelity. If you checked the box, obtain and attach the compliance officer’s letter of
approval (“407 letter”) and indicate the name and address of the entity with which you are associated below. Failure to
include an approval letter may delay the processing of your request. We must tell the associated entity that you have
applied for this account.
Check here if your association is through your employer. (If you checked this box, you are not required to complete the
information below.)
Associated company name
Address
City
State
ZIP
Control
Check this box if you are a control person associated with either (a) another member, (b) a member organization, or (c) an
immediate family/household member of a control person, or are associated with a publicly traded company under SEC
Rule 144 (this would include, but is not limited to, a director, 10% shareholder, policy-making officer, and members of
the board of directors).
Trading Symbol
Company Name
3rd Trustee
Full legal name
Title
Permanent address
(no P.O. boxes)
Mailing address
(if different from above)
Street
City
StateZip
Street
City
StateZip
Date of birth (mm/dd/yyyy)
Social Security number
or Taxpayer ID Number
Phone numbers Evening
Daytime
Countries of citizenship
U.S.
Other(s)
UNEXPIRED GOVERNMENT ID
Ext.
Country of
tax residence
U.S.
Other __________________
(FOREIGN CITIZENS ONLY)
Identification document must have a reference number and photo. Please attach a photocopy.­
Place of birth
City
Immigration status
State/Province
Permanent resident
Non-permanent resident
Country
Non-resident
Check which type of document you are providing: U.S. driver’s license
DHS permanent resident card
Passport with U.S. visa
Passport without U.S. visa
Foreign national identity document
Document number and country of issuance
(Number from the document checked above)
Page 3 of 8
Employment
Authorization Document (EAD)
2
TRUSTEES
(CONTINUED)
3rd Trustee (continued)
Self-Employed and my employment
address is the same as my legal address
Employment status
Employed
Not employed
Retired
Self-Employed and I am providing
my employment address below
Occupation:
Employer’s name:
Employer’s address:
Street
City
StateZip
ASSOCIATIONS
Check this box if you are associated with, or employed by, a stock exchange or a member firm of an exchange or FINRA, a
municipal securities dealer, or Fidelity. If you checked the box, obtain and attach the compliance officer’s letter of
approval (“407 letter”) and indicate the name and address of the entity with which you are associated below. Failure to
include an approval letter may delay the processing of your request. We must tell the associated entity that you have
applied for this account.
Check here if your association is through your employer. (If you checked this box, you are not required to complete the
information below.)
Associated company name
Address
City
State
ZIP
Control
Check this box if you are a control person associated with either (a) another member, (b) a member organization, or (c) an
immediate family/household member of a control person, or are associated with a publicly traded company under SEC
Rule 144 (this would include, but is not limited to, a director, 10% shareholder, policy-making officer, and members of the
board of directors).
Trading Symbol
Company Name
4th Trustee
Full legal name
Title
Permanent address
(no P.O. boxes)
Mailing address
(if different from above)
Street
City
StateZip
Street
City
StateZip
Date of birth (mm/dd/yyyy)
Social Security number
or Taxpayer ID Number
Phone numbers Evening
Daytime
Countries of citizenship
U.S.
Other(s)
UNEXPIRED GOVERNMENT ID
Ext.
Country of
tax residence
U.S.
Other __________________
(FOREIGN CITIZENS ONLY)
Identification document must have a reference number and photo. Please attach a photocopy.­
Place of birth
City
Immigration status
State/Province
Permanent resident
Non-permanent resident
Country
Non-resident
Check which type of document you are providing: U.S. driver’s license
DHS permanent resident card
Passport with U.S. visa
Passport without U.S. visa
Foreign national identity document
Document number and country of issuance
(Number from the document checked above)
Page 4 of 8
Employment
Authorization Document (EAD)
2
TRUSTEES
(CONTINUED)
4th Trustee (continued)
Employment status
Employed
Not employed
Retired
Self-Employed and my employment
address is the same as my legal address
Self-Employed and I am providing
my employment address below
Occupation:
Employer’s name:
Employer’s address:
Street
City
StateZip
ASSOCIATIONS
Check this box if you are associated with, or employed by, a stock exchange or a member firm of an exchange or FINRA, a
municipal securities dealer, or Fidelity. If you checked the box, obtain and attach the compliance officer’s letter of
approval (“407 letter”) and indicate the name and address of the entity with which you are associated below. Failure to
include an approval letter may delay the processing of your request. We must tell the associated entity that you have
applied for this account.
Check here if your association is through your employer. (If you checked this box, you are not required to complete the
information below.)
Associated company name
Address
City
State
ZIP
Control
Check this box if you are a control person associated with either (a) another member, (b) a member organization, or (c) an
immediate family/household member of a control person, or are associated with a publicly traded company under SEC
Rule 144 (this would include, but is not limited to, a director, 10% shareholder, policy-making officer, and members of the
board of directors).
Trading Symbol
3
Company Name
BENEFICIAL OWNERSHIP FOR TRUSTS
Please complete the information below for the grantor and any additional individual(s) named in the trust (other than the
grantor or trustee(s)) authorized to make changes to the trustees. These individuals will not have any authority to take action
on this account.
Please make duplicates of this page for additional individuals.
GRANTOR
Please complete this section for the grantor. If the grantor is deceased, please attest to that by checking here, and complete the
name and date of death fields.
Full legal name
Date of birth
(mm/dd/yyyy)
Date of death
Permanent address
Social Security number
Country of citizenship
U.S.
Other(s)
Page 5 of 8
(mm/dd/yyyy)
3
BENEFICIAL OWNERSHIP FOR TRUSTS
UNEXPIRED GOVERNMENT ID
a photocopy.­
Place of birth
(CONTINUED)
(FOREIGN CITIZENS ONLY) Identification document must have a reference number and photo. Please attach
CityState/ProvinceCountry
Immigration status
Permanent resident
Non-permanent resident
Non-resident
Check which type of document you are providing: U.S. driver’s license
DHS permanent resident card
Passport without U.S. visa
Passport with U.S. visa
Employment
Authorization Document
Foreign national identity document
Document number and country of issuance
(Number from the document checked above)
ADDITIONAL INDIVIDUAL WITH APPOINT/REMOVE AUTHORITY
If the name provided below is another trust or an entity, additional information and documentation will be required.
Full legal name
Date of birth
Social Security number
(mm/dd/yyyy)
Permanent address
Country of citizenship
U.S.
Other(s)
UNEXPIRED GOVERNMENT ID
(FOREIGN CITIZENS ONLY) Identification document must have a reference number and photo. Please attach a photocopy.­
Place of birth
City
Immigration status
State/ProvinceCountry
Permanent resident
Non-permanent resident
Non-resident
Check which type of document you are providing: U.S. driver’s license
DHS permanent resident card
Passport without U.S. visa
Passport with U.S. visa
Employment
Authorization Document
Foreign national identity document
Document number and country of issuance
(Number from the document checked above)
4
SIGNATURE(S)
4a.The undersigned certify that the Trust indicated in Section 1 has the Trustees listed in Section 2.
4b. Fidelity Brokerage Services LLC and its affiliates (together “Fidelity” or “you”) have the authority to accept orders and other
instructions relative to the Trust accounts identified herein from those individuals or entities listed in Section 2(a). They
may execute any documents on behalf of the Trust which you may require. By signing this form, the Trustee(s) hereby
certifies(y) that you are authorized to follow the instructions of any Trustee and to deliver funds, securities, or any other
assets in the 529 College Savings Plan account identified herein to any Trustee or on any Trustee’s instructions, including
delivering assets to a Trustee personally. Fidelity, in its sole discretion and for its sole protection, may require the written
consent of any or all Trustees prior to acting upon the instructions of any Trustee.
4c.There are no other Trustee(s) of the Trust other than those listed in Section 2(a).
4d.Should only one person execute this agreement, it shall be a representation that the signer is the sole Trustee. Where
applicable, plural references in this certification shall be deemed singular.
Page 6 of 8
4
SIGNATURE(S) (CONTINUED)
4e.We, the Trustees, have the power under the Trust and applicable law to enter into all transactions and issue all instructions that we make in this account. Such power may include, without limitation, the authority to buy, sell, exchange,
convert, redeem and withdraw assets and to trade applicable interests in investment portfolios for and at the risk of the
Trust. We understand that all orders and transactions will be governed by the terms and conditions of the Participation
Agreement and all other account agreements applicable to this account.
4f. We, the Trustees, have the power to change the Beneficiary on the 529 College Savings Plan account.
4g.We, the Trustees, jointly and severally, indemnify you and hold you harmless from any claim, loss, expense or other
liability for effecting any transactions, and acting upon any instructions given by the Trustees. We, the Trustees, certify
that any and all transactions effected and instructions given on this account will be in full compliance with the Trust.
4h.We, the Trustees, agree to inform you in writing of any change in the composition of the Trustees, or any other event
which could alter the certifications made above.
4i. We, the Trustees, agree that any information we give to Fidelity on this account will be subject to verification, and we
authorize you to obtain a credit report about me (any of us) individually at any time. Upon written request, Fidelity will
provide the name and address of the credit reporting agency used.
4j. If I/we have not checked the box for Affiliations or Control, I/we represent and warrant that I/we am/are not affiliated
with or employed by a stock exchange or a broker-dealer or I/we am/are not a control person or affiliate or a public
company under SEC Rule 144 (such as a director, 10% shareholder, or policy-making officer), or an immediate family
or household member of such a person.
4k.I represent and warrant that: 1) I have personally printed the foregoing 529 Plan Trustee Certification of Investment
Powers form, and 2) the terms of this form have not been changed and are identical to the terms as originally set forth
by Fidelity. I acknowledge that any alteration of the form’s original terms shall be null and void and I shall be bound by
the terms of the original form as set forth by Fidelity. I understand and acknowledge that the above-referenced agreement may be terminated in the event that Fidelity Brokerage Services LLC or any of its agents or affiliates has reasonable
grounds to believe the foregoing is untrue, or the form has been altered.
CERTIFIED TO FIDELITY BY (all Trustees must sign and date):
TRUSTEE SIGNATURE DATE TRUSTEE SIGNATURE X
TRUSTEE SIGNATURE X
DATE DATE
X
TRUSTEE SIGNATURE X
Page 7 of 8
DATE
397525.4.0
PO Box 770001
Cincinnati, OH 45277-0002
Fidelity Brokerage Services LLC, Member NYSE, SIPC
Page 8 of 8
529TCIP-SCF-1212
1.772565.106