Form F5M4Mdst – Fill Out and Use This PDF

1 Account Information

Account Holder (Trust name if applicable)	Social Security/Tax ID Number
Custodian or Trustee (if applicable)
Beneficiary	Social Security Number

Check only ONE payee option:

Account Holder.

Beneficiary.

Estate of Beneficiary. Provide a certified copy of the court-issued document that appoints the executor of the estate and a copy of the Beneficiary´s death certificate.

Beneficiary and Eligible Educational Institution, jointly. Provide the institution name in Section 3B.

Eligible Educational Institution for benefit of (FBO) Beneficiary. The institution address is required in Section 3B.

2	Distribution Instructions

Provide the Account number and amount to distribute. If the distribution is for the total Account balance, the Account will close, and any Automatic Monthly Contributions (AMC) will stop unless you check the box below:

Continue AMC.

NOTE: See the Plan Disclosure Statement for information on Qualified and Non-Qualified Distributions, taxes, and penalties.

ACCOUNT NUMBER	AMOUNT	ALL
	$	
	$	
Total	$

For more Accounts, check this box and attach a separate page.

3 Payment Instructions

3A Payee

The Beneficiary’s Social Security number (SSN) will be used for tax reporting unless the check is payable to the Account Holder, in which case the Account Holder’s SSN will be used.

Checks will be mailed to the address on record of the payee checked in Section 3A unless you provide a different address below or check the box to transfer to the bank on file. If you provide a new address, a signature guarantee is required unless the check is payable to the Eligible Educational Institution FBO Beneficiary.

Institution Name*

Student ID*

Address — Line 1*

Address — Line 2*

City*	State*	ZIP Code*

*NOTE: Required if payee is the Eligible Educational Institution FBO Beneficiary.

Make this the payee´s address of record.

TRANSFER TO BANK ON FILE. The payee must be an Account Holder or Beneficiary and listed as an owner on the bank account.

TRANSFER TO NEW BANK. Enclose a voided check or preprinted savings deposit slip.

Checking account or  Savings account

Check one:  Add bank  Replace current bank

Check transfer method:

Automated Clearing House (ACH).

Wire. NOTE: Your bank may charge a fee.

4 Signature

4A Account Holder, Custodian, or Trustee

By signing this form, I authorize this distribution and understand and hereby certify that:

•The information in this form is accurate. As described in the College Investment Plan Disclosure Statement, I agree to hold harmless the College Savings Plans of Maryland, the Trust, the Trustee, and T. Rowe Price for any losses arising out of any misrepresentations made by me or breach of acknowledgments contained in this form or if I distribute assets to a payee for the purpose of reducing my associated tax liability.

•I authorize the Trust and T. Rowe Price, their agents, and their affiliates to act on instructions in this form believed to be genuine and from me.

•If I am withdrawing my entire Account balance, I understand that my Account will be closed unless I indicated in Section 2 that I want to continue AMC.

•I understand that it is my responsibility to maintain accu- rate records as may be required by the IRS to substantiate this distribution for tax purposes.

NOTE: To remove a Custodian, complete the Custodian Removal form.

Signature guarantee is required if:

•The distribution is $50,000 or more

•The distribution is sent to an address not on record

•The distribution is sent to a new bank account

SIGNATURE AND DATE REQUIRED

Account Holder or Custodian (if Account Holder	Date (mm/dd/yyyy)
is a minor) or Trustee(s)

X

4B Signature Guarantee

You can obtain the Medallion signature guarantee from most banks, savings institutions or broker-dealers. We cannot accept guarantees from notaries public or non-Medallion guarantors. The level of coverage provided by the guarantor’s stamp must cover the dollar amount of the transaction or it may be rejected.

MEDALLION SIGNATURE GUARANTEE

Place Medallion Stamp Below:

Name of Institution

Print Name of Person Providing

Guarantee

Date (mm/dd/yyyy)