Fillable Printable Limited Power of Attorney - Nevada

Limited Power of Attorney - Nevada

CSNVU_FRM_01176G 0115 — Page 1 of 4

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SSgA Upromise 529 Plan

Agent Authorization / Limited Power of Attorney

• Complete this form to designate a financial advisor, individual, corporation, or other entity as your agent with limited authority to act on your

SSgA Upromise 529 Plan Account(s). To grant an agent complete powers to act on your SSgA Upromise 529 Plan Account(s), please complete

the Power of Attorney Form.

• You may only designate one level of authorization in Section 3 for the Account(s) listed on this form. To grant a different level of

authorization for your other Account(s), please complete a separate form.

• This Agent Authorization/Limited Power of Attorney Form must be signed by the Account Owner and notarized in Section 4.

• If there is anything about this form that you do not understand, you should ask a lawyer of your own choosing to explain it to you.

• Type in your information and print out the completed form, or print clearly, preferably in capital letters and black ink. Mail the form to the

address below. Do not staple.

Forms can be downloaded from our website at www.ssga.upromise529.com, or you can call us to order any form — or request assistance in

completing this form — at 1.800.587.7305 any business day from 8 a.m. to 8 p.m. Eastern time.

NOTICE: THIS DOCUMENT GIVES YOUR AGENT THE LIMITED POWER TO ACT FOR YOU, WITHOUT YOUR CONSENT, IN ANY

WAY THAT YOU COULD ACT FOR YOURSELF. THE POWERS GRANTED BY THIS DOCUMENT ARE BROAD AND SWEEPING. IF YOU

HAVE ANY QUESTIONS ABOUT THESE POWERS, OBTAIN COMPETENT LEGAL ADVICE. YOU MAY REVOKE THIS LIMITED POWER

OF ATTORNEY IF YOU LATER WISH TO DO SO.

THE PURPOSE OF THIS POWER OF ATTORNEY IS TO GIVE THE PERSON YOU DESIGNATE (YOUR “AGENT”) LIMITED POWERS TO

HANDLE YOUR ACCOUNT(S) WITH THE SSgA UPROMISE 529 PLAN, WHICH MAY INCLUDE POWERS TO MAKE INVESTMENT

DECISIONS, CONTRIBUTIONS, WITHDRAWALS, AND TAKE OTHER ACTION IN CONNECTION WITH YOUR SSgA UPROMISE 529

PLAN ACCOUNT(S) WITHOUT ADVANCE NOTICE TO YOU OR APPROVAL BY YOU. THIS FORM DOES NOT IMPOSE A DUTY ON

YOUR AGENT TO EXERCISE GRANTED POWERS; BUT WHEN POWERS ARE EXERCISED, YOUR AGENT MUST USE DUE CARE TO

ACT LOYALLY FOR YOUR BENEFIT AND IN ACCORDANCE WITH THE PROVISIONS OF THIS FORM AND MUST KEEP A RECORD

OF ALL RECIEPTS, DISBURSEMENTS AND TRANSACTIONS MADE ON YOUR BEHALF UNTIL YOU REVOKE THIS POWER OF

ATTORNEY OR A COURT ACTING ON YOUR BEHALF TERMINATES IT. YOUR AGENT MAY EXERCISE THE POWERS GIVEN HERE

THROUGHOUT YOUR LIFETIME, EVEN AFTER YOU BECOME DISABLED.

YOU AND YOUR AGENT MAY HAVE OTHER RIGHTS, POWERS, OR DUTIES UNDER NEVADA LAW NOT SPECIFIED IN THIS FORM.

Return this form and any other required documents to:

SSgA Upromise 529

P.O. Box 55578

Boston, MA 02205-5578

For overnight delivery or registered mail, send to:

SSgA Upromise 529

95 Wells Ave., Suite 155

Newton, MA 02459-3204

CSNVU_FRM_01176G 0115 — Page 2 of 4

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1. Account Owner information

Account Number (List all that apply. To list more than three Accounts,

use a separate sheet.)

Social Security Number or Taxpayer Identiﬁcation Number (Required)

Name of Account Owner (ﬁrst, middle initial, last)

Permanent Street Address (P.O. box is not acceptable.)

City State Zip Code

Telephone Number (In case we have a question about your Account.)

2. Agent information

Note: If your agent is a corporation or other entity, the entity must also complete and submit a SSgA Upromise 529 Organization

Resolution Form.

Relationship of Agent to Account Owner (Check one.)

Financial Advisor Other (Provide Social Security number or other Tax ID number.)

Name of Agent (ﬁrst, middle initial, last)

Financial Advisor Firm Name (If applicable)

Financial Advisor ID Number (If applicable)

Mailing Address

City State Zip Code

Telephone Number

CSNVU_FRM_01176G 0115 — Page 3 of 4

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3. Authorization level

I, the Account Owner listed in Section 1, appoint the Agent listed in Section 2, as my agent (please initial the appropriate level of

access that applies to the Account(s) listed in Section 1).

Note: If you have more than one Account and you wish to designate different levels of access for your different Account(s), complete

a separate form for each Account.

Level 1 — Account Inquiry Access. To obtain information about my Account(s), and receive duplicate Account

statements from the SSgA Upromise 529 Plan.*

Level 2 — Account Inquiry Access, Contributions, and Exchanges. To obtain information about my Account(s), and

receive duplicate Account statements from the SSgA Upromise 529 Plan. To contribute money to the above-referenced

Account(s) and to move money among Investment Options within each of the above-referenced Account(s).*

Level 3 — Account Inquiry Access, Contributions, Exchanges, and Disbursements. To obtain information about

my Account(s), and receive duplicate Account statements from the SSgA Upromise 529 Plan. To contribute money to

the above-referenced Account(s) and to move money among Investment Options within each of the above-referenced

Account(s). To withdraw, now or in the future, money from the above-referenced Account(s).*

* The authority granted herein is limited to the level of authority speciﬁed above. My agent shall have no authority to take any other

action, including, but not limited to:

• Changing the address of record on my Account(s),

• Adding, deleting, or changing any banking information with respect to my Account(s),

• Changing the Beneﬁciary,

• Signing or e-signing an Account application or otherwise opening a new registration on my behalf, or

• Transferring assets to a new registration.

Account Owner Certification

Do you reside in a hospital, assisted living facility or facility for skilled nursing? If you answer “Yes” you must attach to this form a

certiﬁcation of your competency from a physician, psychologist or psychiatrist.

Yes No

CSNVU_FRM_01176G 0115 — Page 4 of 4

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4. Signature and notarization — YOU MUST SIGN BELOW

UNLESS YOU DIRECT OTHERWISE, THIS LIMITED POWER OF ATTORNEY IS EFFECTIVE IMMEDIATELY AND WILL CONTINUE UNTIL IT

IS REVOKED OR TERMINATED AS SPECIFIED BELOW. THIS LIMITED POWER OF ATTORNEY WILL CONTINUE TO BE EFFECTIVE EVEN

IF YOU BECOME DISABLED, INCAPACITATED, OR INCOMPETENT.

THIS LIMITED POWER OF ATTORNEY MAY BE REVOKED BY YOU AT ANY TIME. ABSENT REVOCATION, THE AUTHORITY GRANTED

IN THIS POWER OF ATTORNEY IS EFFECTIVE WHEN THIS LIMITED POWER OF ATTORNEY IS SIGNED AND CONTINUES IN EFFECT

UNTIL YOUR DEATH.

I agree that any third party who receives a copy of this document may act under it. Revocation or termination of the power of attorney

due to my death, court determination or any other reason is not effective as to a third party until the third party receives written notice

of the revocation or termination and the third party has had a reasonable amount of time to act on such notice. I, for myself and for

my heirs, executors, legal representatives and assigns, agree to indemnify the SSgA Upromise 529 Plan, the Board of Trustees of the

College Savings Plans of Nevada, the State of Nevada, Ascensus Broker Dealer Services, Inc., Ascensus Investment Advisors, LLC.,

Sallie Mae Bank, State Street Global Advisors, and any of their respective afﬁliates, agents, and employees, and any third party acting

hereunder (any of such persons, individually, a “third party”) in connection with SSgA Upromise 529 Plan, for any claims that arise

against the third party because of reliance on this power of attorney.

IF THERE IS ANYTHING ABOUT THIS FORM THAT YOU DO NOT UNDERSTAND, CONSULT A LAWYER KNOWLEDGEABLE IN NEVADA

LAW BEFORE SIGNING THIS FORM.

SIGNATURE

Signature of Account Owner Date (mm/dd/yyyy)

Your signature must be notarized. See below. We cannot accept a signature guarantee in place of a notary’s seal.

STATE OF ___________________________ )

)ss.:

COUNTY OF _________________________ )

This document was acknowledged before me on ________ (date) by _______________________________________

(name of Account Owner), who certiﬁes the correctness of the signature of the Account Owner.

SIGNATURE

Signature of Notary Date (mm/dd/yyyy)

Name of Notary (ﬁrst, middle initial, last)

My commission expires:

Date (mm/dd/yyyy)

Notary to place seal here

Applies to signature in Section 4.

SSgA Upromise 529 is Administered by the Board of Trustees of the College Savings Plans of Nevada, chaired by

Nevada State Treasurer. Program Management Services are provided by Ascensus Broker Dealer Services, Inc.

Member, FINRA, Securities Investor Protection Corporation (SIPC).

State Street Global Advisors and SSgA are registered trademarks of State Street Corporation.

Upromise and the Upromise logo are registered service marks of Upromise, Inc.