Form  5305-EA                     Coverdell Education Savings Custodial Account                                           Do not file 
(Rev. October 2016)                                                                                                       with the Internal  
Department of the Treasury                   (Under section 530 of the Internal Revenue Code)                             Revenue Service 
Internal Revenue Service 
Name of depositor 
                                                                                                             Check if amendment  . .  .  ▶
Name of designated beneficiary 

Address of designated beneficiary                                         Date of birth of designated beneficiary 

Name of responsible individual (generally the parent or guardian of the designated beneficiary) 

Address of responsible individual 

Name of custodian                                                         Address or principal place of business of custodian 

The depositor named above is establishing a Coverdell education savings account under section 530 for the benefit of the designated  
beneficiary exclusively to pay for the qualified elementary, secondary, and higher education expenses, within the meaning of section 530(b)(2), 
of such designated beneficiary. 
The depositor assigned the custodial account                                                           dollars  ($                 )  in cash. 

The depositor and the custodian make the following agreement: 
                                                                   Article I 
The custodian may accept additional cash contributions provided the designated beneficiary has not attained the age of 18 as of the date 
such contributions are made. Contributions by an individual contributor may be made for the tax year of the designated beneficiary by the due 
date of the beneficiary’s tax return for that year (excluding extensions). Total contributions that are not rollover contributions described in 
section 530(d)(5) are limited to $2,000 for the tax year. In the case of an individual contributor, the $2,000 limitation for any year is phased out 
between modified adjusted gross income (AGI) of $95,000 and $110,000. For married individuals filing jointly, the phase-out occurs between 
modified AGI of $190,000 and $220,000. Modified AGI is defined in section 530(c)(2). 
                                                                 Article II 
No part of the custodial account funds may be invested in life insurance contracts, nor may the assets of the custodial account be  
commingled with other property except in a common trust fund or a common investment fund (within the meaning of section 530(b)(1)(D)). 
                                                                 Article III 
1.    Any balance to the credit of the designated beneficiary on the date on which he or she attains age 30 shall be distributed to him or her 
      within 30 days of such date. 
2.    Any balance to the credit of the designated beneficiary shall be distributed within 30 days of his or her death unless the designated  
      death beneficiary is a family member of the designated beneficiary and is under the age of 30 on the date of death. In such case, that 
      family member shall become the designated beneficiary as of the date of death. 
                                                                 Article IV 
The depositor shall have the power to direct the custodian regarding the investment of the above-listed amount assigned to the custodial 
account (including earnings thereon) in the investment choices offered by the custodian. The responsible individual, however, shall have the 
power to redirect the custodian regarding the investment of such amounts, as well as the power to direct the custodian regarding the 
investment of all additional contributions (including earnings thereon) to the custodial account. In the event that the responsible individual 
does not direct the custodian regarding the investment of additional contributions (including earnings thereon), the initial investment direction 
of the depositor also will govern all additional contributions made to the custodial account until such time as the responsible individual 
otherwise directs the custodian. Unless otherwise provided in this agreement, the responsible individual also shall have the power to direct 
the custodian regarding the administration, management, and distribution of the account. 
                                                                 Article V 
The “responsible individual” named by the depositor shall be a parent or guardian of the designated beneficiary. The custodial account shall 
have only one responsible individual at any time. If the responsible individual becomes incapacitated or dies while the designated beneficiary 
is a minor under state law, the successor responsible individual shall be the person named to succeed in that capacity by the preceding 
responsible individual in a witnessed writing or, if no successor is so named, the successor responsible individual shall be the designated 
beneficiary’s other parent or successor guardian. Unless otherwise directed by checking the option below, at the time that the designated 
beneficiary attains the age of majority under state law, the designated beneficiary becomes the responsible individual. If a family member 
under the age of majority under state law becomes the designated beneficiary by reason of being a named death beneficiary, the responsible 
individual shall be such designated beneficiary’s parent or guardian. 
    Option (This provision is effective only if checked): The responsible individual shall continue to serve as the responsible individual for the 
custodial account after the designated beneficiary attains the age of majority under state law and until such time as all assets have been 
distributed from the custodial account and the custodial account terminates. If the responsible individual becomes incapacitated or dies after 
the designated beneficiary reaches the age of majority under state law, the responsible individual shall be the designated beneficiary. 
                                                Cat. No. 25204K                                                     Form  5305-EA  (Rev. 10-2016) 

Form 5305-EA (Rev. 10-2016)                                                                                                                       Page  2 
                                                                      Article VI 
The responsible individual          may or         may not change the beneficiary designated under this agreement to another member of 
the designated beneficiary’s family described in section 529(e)(2) in accordance with the custodian’s procedures. 
                                                                      Article VII 
1.    The depositor agrees to provide the custodian with all information necessary to prepare any reports required by section 530(h). 
2.    The custodian agrees to submit to the Internal Revenue Service (IRS) and responsible individual the reports prescribed by the IRS. 
                                                                   Article VIII 
Notwithstanding any other articles which may be added or incorporated, the provisions of Articles I through III will be controlling. Any  
additional articles inconsistent with section 530 and the related regulations will be invalid. 

                                                                      Article IX 
This agreement will be amended as necessary to comply with the provisions of the Code and the related regulations. Other amendments 
may be made with the consent of the depositor and the custodian whose signatures appear below. 

                                                                      Article X 
Article X may be used for any additional provisions. If no other provisions will be added, draw a line through this space. If provisions are 
added, they must comply with applicable requirements of state law and the Internal Revenue Code. 

Depositor’s signature                                                                                  Date 

Custodian’s signature                                                                                  Date 

Witness’ signature                                                                                     Date 
                                             (Use only if signature of the depositor or the custodian is required to be witnessed.) 
General Instructions                               Definitions                                         return for which is filed to report the depositor's 
                                                                                                       information. The  designated beneficiary’s social 
Section references are to the Internal Revenue     Custodian. The custodian must be a bank or          security number is the identification number of 
Code unless otherwise noted.                       savings and loan association, as defined in         his or her Coverdell ESA. If the designated 
                                                   section 408(n), or any person who has the           beneficiary is a nonresident alien, the designated 
What's New                                         approval of the IRS to act as custodian. Any        beneficiary’s individual taxpayer identification 
Military death gratuity. Families of soldiers who  person who may serve as a custodian of a            number is the identification  number of his or her 
receive military death benefits may contribute,    traditional IRA may serve as the custodian of a     Coverdell ESA. An  employer identification 
subject to certain limitations, up to 100 percent  Coverdell ESA.                                      number (EIN) is  required only for a Coverdell 
of such benefits into an educational savings       Depositor. The depositor is the person who          ESA for which a  return is filed to report unrelated 
account. Publication 970, Tax Benefits for         establishes the custodial account.                  business  income. An EIN is required for a 
Education, explains the rules for rolling over the Designated beneficiary. The designated              common  fund created for Coverdell ESAs. 
military death gratuity and lists eligible family  beneficiary is the individual on whose behalf the 
members.                                           custodial account has been established.             Specific Instructions 
Purpose of Form                                    Family member. Family members of the                Note: The age limitation restricting contributions, 
                                                   designated beneficiary include his or her           distributions, rollover contributions, and change 
Form 5305-EA is a model custodial account          spouse, child, grandchild, sibling, parent, niece   of beneficiary are waived for a designated 
agreement that meets the requirements of           or nephew, son-in-law, daughter-in-law, father-     beneficiary with special needs. 
section 530(b)(1) and has been pre-approved by     in-law, mother-in-law, brother-in-law, or sister-in-Article X. Article X and any that follow may  
the IRS. A Coverdell education savings account     law, and the spouse of any such individual. A first incorporate additional provisions that are agreed 
(ESA) is established after the form is fully       cousin, but not his or her spouse, is also a        to by the depositor and custodian to complete 
executed by both the depositor and the             “family member.”                                    the agreement. They may include, for example, 
custodian. This account must be created in the 
United States for the exclusive purpose of         Responsible individual. The responsible             provisions relating to: definitions, investment 
paying the qualified elementary, secondary, and    individual, generally, is a parent or guardian of   powers, voting rights, exculpatory provisions, 
higher education expenses of the designated        the designated beneficiary. However, under          amendment and termination, removal of the 
beneficiary.                                       certain circumstances, the responsible individual   custodian, custodian’s fees, state law 
If the model account is a trust account, see       may be the designated beneficiary.                  requirements, treatment of excess contributions, 
                                                                                                       and prohibited transactions with the depositor, 
Form 5305-E, Coverdell Education Savings           Identification Numbers                              designated beneficiary, or responsible individual, 
Trust Account.                                                                                         etc. Attach additional pages as necessary. 
                                                   The depositor’s and designated beneficiary’s  
Do not file Form 5305-EA with the IRS.             social security numbers will serve as their         Optional provisions in Article V and Article VI. 
Instead, the depositor must keep the  completed    identification numbers. If the depositor is a       Form 5305-EA may be reproduced in a manner 
form in its records.                               nonresident alien and does not have an              that provides only those optional provisions 
                                                   identification number, write “Foreign” on the       offered by the custodian. 

                                                                                                                                    Form  5305-EA  (Rev. 10-2016)