Star One Credit Union
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Star One Coverdell Education Savings Account (ESA) Contribution Form

Please complete, print, sign, and mail to: Star One Credit Union, PO Box 3643, Sunnyvale, CA 94088-3643.
You may also fax your completed form to (408) 543-5203.

Designated Beneficiary's Information
Minor's Name
Birth Date ESA Account Number

Contributor's Information
Contributor's Name
Street Address
City, State, Zip
Telephone Number
Social Security Number Relationship to Minor

Contribution Information
Deposit Amount $
Contribution for Tax Year Contribution Date

Deposit Instructions
Cash/Check Deposit $
or Transfer from Account #

Signature
I certify the information contained in this form to be correct and I have not exceeded the total contribution limit allowable by federal tax regulations to the ESA or the tax year stated above. I certify that the deposit described above is eligible to be contributed to the ESA and I authorize the deposit in the manner described above. I certify that all of the information provided by me is correct and may be relied upon by the Custodian and the ESA Responsible Individual.
__________________________________________ _________________________________
(Contributor) (Date)
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