CollegeWealth® 529 Savings Account Application

Please read the following:

Understanding Your Relationship Disclosure
Collegewealth 529 Truth In Savings and Program Description

I hereby apply to establish a CollegeWealth 529 Account with the Virginia College Savings Plan through the Participating Bank as that term is defined in the Program Description and acknowledge that I have received, read and agreed to the terms set forth in the Program Description, Bank Fee Disclosure Statement and this application, as these documents may be modified from time to time.

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CollegeWealth® 529 Savings Account Application

Your submission of this application acknowledges that you have read and printed the disclosures. If you do not have the ability to print the disclosures, please contact one of our locations prior to submitting the application.

Ownership

Single Owner (Account Owner and Beneficiary is the same individual)

Account Owner & Beneficiary (Account Owner designates another individual as the beneficiary)

Account Owner Information (Required)

Name (First M. Last)
Date of Birth (mm/dd/yyyy)
Social Security Number:
Address
City, State Zip	,
Home Phone Number	( ) -
Work Phone Number	( ) -
Driver's License Number		State
Issue Date		Expiration Date
E-mail
Relationship to Beneficiary

Beneficiary Information (Required) (This is the person for whom the money is to be used for higher education)

Name (First M. Last)
Address
City, State Zip	,
Date of Birth (mm/dd/yyyy)
Social Security Number
Driver's License Number		State
Issue Date		Expiration Date

Successor Owner Information (Optional)
A successor owner will become the owner of the Account in the event the Account Owner dies or becomes legally incompetent. The successor Owner cannot be the same person as the Account Owner. The successor owner must be at least 18 years old at the time of designation.

Name (First M. Last)
Social Security Number
Phone Number	( ) -
Address
City, State Zip	,
Date of Birth (mm/dd/yyyy)

Deposit Information

Initial Deposit	$
Initial Deposit Type

Taxpayer Identification Number Certification

The Social Security Number(s) shown above is my correct SSN.

I am not subject to backup withholding either because I have not been notified that I am subject to backup withholding as a result of a failure to report all interest or dividends, or the Internal Revenue Service has notified me that I am no longer subject to backup withholding.

I am an exempt recipient under the Internal Revenue Service Regulations.

I am not a United States person, or if I am an individual, I am neither a citizen nor a resident of the United States.

I certify under penalties of perjury the statements checked in this section are true.

I authorize Union Bank & Trust to obtain a copy of my current credit report as a condition of acceptance of this application and for the purpose of extension of or renewal of credit.