Fill and Sign the Sc Form Affidavit 2014

Print Save Reset 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 Street Trust Mailing address (if different from above) 2 City State ZIP Street (no P.O. boxes or C/O) City State 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 Street Mailing address (if different from above) City State Zip Street (no P.O. boxes) City State Zip 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 State Zip ASSOCIATIONS  heck this box if you are associated with, or employed by, a stock exchange or a member firm of an exchange or FINRA, a C 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.  heck here if your association is through your employer. (If you checked this box, you are not required to complete the C information below.) Associated entity name Address City State ZIP Control  heck this box if you are a control person associated with either (a) another member, (b) a member organization, or (c) an C 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 State Zip Street City State Zip 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 State Zip ASSOCIATIONS  heck this box if you are associated with, or employed by, a stock exchange or a member firm of an exchange or FINRA, a C 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.  heck here if your association is through your employer. (If you checked this box, you are not required to complete the C information below.) Associated company name Address City State ZIP Control  heck this box if you are a control person associated with either (a) another member, (b) a member organization, or (c) an C 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 Street Mailing address (if different from above) City State Zip Street (no P.O. boxes) City State Zip 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 State Zip ASSOCIATIONS  heck this box if you are associated with, or employed by, a stock exchange or a member firm of an exchange or FINRA, a C 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.  heck here if your association is through your employer. (If you checked this box, you are not required to complete the C information below.) Associated company name Address City State ZIP Control  heck this box if you are a control person associated with either (a) another member, (b) a member organization, or (c) an C 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 Street Mailing address (if different from above) City State Zip Street (no P.O. boxes) City State Zip 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 State Zip ASSOCIATIONS  heck this box if you are associated with, or employed by, a stock exchange or a member firm of an exchange or FINRA, a C 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.  heck here if your association is through your employer. (If you checked this box, you are not required to complete the C information below.) Associated company name Address City State ZIP Control  heck this box if you are a control person associated with either (a) another member, (b) a member organization, or (c) an C 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 City State/Province Country 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 D  ocument 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/Province Country 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 D  ocument 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.  idelity Brokerage Services LLC and its affiliates (together “Fidelity” or “you”) have the authority to accept orders and other F 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