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COVERDELL EDUCATION SAVINGS ACCOUNT CERTIFICATION OF by fcd21015

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									COVERDELL EDUCATION SAVINGS ACCOUNT CERTIFICATION
OF SPECIAL NEEDS STUDENT FORM

For assistance completing this form, please contact a representative at 888.772.2888, Monday - Friday, 9 a.m. to 6 p.m. Eastern Time or visit us online
at oldmutualfunds.com.
In June 2001, Congress modified and renamed the Education IRA to the Coverdell Education Savings Account (sometimes referred to as an ESA).
A Special Needs Student is a person who, because of a physical, mental or emotional condition, or a learning disability, requires additional time to
complete his or her education. Any requirements specified by the Internal Revenue Service must also be satisfied.
The law exempts Special Needs Students from all age requirements under the original laws. This means that Coverdell Education Savings Accounts
may be established for Special Needs Students who are 18 or over, and rollovers and transfers can be made tax-free to family members who are
Special Needs Students, regardless of their age. In addition, Coverdell Education Savings Accounts may be maintained for Special Needs Students
beyond the age of 30.
Complete the Account Information in Section 1 and sign this form in Section 2. If the student is a minor in the state of the student’s residence (or if
the student has reached the age of majority but has not filed a written notice with the Custodian assuming control of the Coverdell Education Savings
Account), the Responsible Individual (Account Manager) controlling the administration of the Coverdell Education Savings Account should sign. If the
student controls the administration of the account, the student should sign. The student will not be certified as having Special Needs until Old Mutual
Funds receives this form.



1    STUDENT
     INFORMATION
                            Student’s Account Number                                                  Social Security Number (required)



                            Student’s Name (first, middle initial, and last)                          Date of Birth (MM/DD/YYYY) (required)



                            Mailing Address                                                           Apt. or Unit Number



                            Street Address (if P.O. Box is listed above)



                            City                                                        State         Zip



                            Daytime Telephone Number                                                  Evening Telephone Number



                            E-mail Address



2    CERTIFICATION
     & SIGNATURE
                            By signing this form I certify that the Student named in Section 1 of this form is a Special Needs Student (as defined by
                            the IRS). I understand that adverse income tax consequences (including possible penalties) may apply for providing false or
                            incorrect information.
                            Unsigned forms will be returned and will not be honored.



                            Signature and Date



                            Printed Name




MAILING                     Regular Mail:                                                       Express, Certified or Registered Mail:
INSTRUCTIONS                Old Mutual Funds                                                    Old Mutual Funds
                            P.O. Box 219534                                                     210 West 10th Street, 8th Floor
                            Kansas City, MO 64121-9534                                          Kansas City, MO 64105
                                                                                                                                         M-08-880 09/2008

								
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