Form  5305-E                        Coverdell Education Savings Trust 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 grantor 
                                                                                                          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 trustee                                        Address or principal place of business of trustee 

The grantor named above is establishing a Coverdell education savings trust 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 grantor has assigned the trust                                                                    dollars  ($               )  in cash. 

The grantor and the trustee make the following agreement: 
                                                                  Article I 
The trustee 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 trust account funds may be invested in life insurance contracts, nor may the assets of the trust 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 grantor shall have the power to direct the trustee regarding the investment of the above-listed amount assigned to the trust (including 
earnings thereon) in the investment choices offered by the trustee. The responsible individual, however, shall have the power to redirect the 
trustee regarding the investment of such amounts, as well as the power to direct the trustee regarding the investment of all additional 
contributions (including earnings thereon) to the trust. In the event that the responsible individual does not direct the trustee regarding the 
investment of additional contributions (including earnings thereon), the initial investment direction of the grantor also will govern all additional 
contributions made to the trust account until such time as the responsible individual otherwise directs the trustee. Unless otherwise provided 
in this agreement, the responsible individual also shall have the power to direct the trustee regarding the administration, management, and 
distribution of the account. 
                                                                  Article V 
The “responsible individual” named by the grantor shall be a parent or guardian of the designated beneficiary. The trust 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 individualfor the 
trust after the designated beneficiary attains the age of majority under state law and until such time as all assets have been distributed from 
the trust and the trust terminates. If the responsible individual becomes incapacitated or dies after the designatedbeneficiary reaches the age 
of majority under state law, the responsible individual shall be the designated beneficiary. 

                                                                  Cat. No. 25205V                                   Form 5305-E (Rev. 10-2016) 

Form 5305-E (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 trustee’s procedures. 
                                                                      Article VII 
1. The grantor agrees to provide the trustee with all information necessary to prepare any reports required by section 530(h). 
2. The trustee 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 grantor and trustee 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. 

Grantor’s signature                                                                                    Date 

Trustee’s signature                                                                                    Date 

Witness’ signature                                                                                     Date 
                                                     (Use only if signature of the grantor or the trustee is required to be witnessed.) 
General Instructions                                 section 408(n), or any person who has the         beneficiary is a nonresident alien, the  
                                                     approval of the IRS to act as trustee. Any        designated beneficiary’s individual taxpayer  
Section references are to the Internal               person who may serve as a trustee of a            identification number is the identification 
Revenue Code unless otherwise noted.                 traditional IRA may serve as the trustee of a     number of his or her Coverdell ESA. An  
What's New                                           Coverdell ESA.                                    employer identification number (EIN) is 
Military death gratuity. Families of soldiers        Grantor. The grantor is the person who            required only for a Coverdell ESA for which a  
who receive military death benefits may              establishes the trust account.                    return is filed to report unrelated business 
                                                                                                       income. An EIN is required for a common fund 
contribute, subject to certain limitations, up to    Designated beneficiary. The designated            created for Coverdell ESAs.
100 percent of such benefits into an                 beneficiary is the individual on whose behalf  
educational savings account. Publication 970,        the trust account has been established. 
                                                                                                       Specific Instructions
for rolling over the military death gratuity and     designated beneficiary include his or her         Note: 
Tax Benefits for Education, explains the rules       Family member. Family members of the                    The age limitation restricting 
lists eligible family members.                       spouse, child, grandchild, sibling, parent,       contributions, distributions, rollover 
Purpose of Form                                      niece or nephew, son-in-law, daughter-in-law,     contributions, and change of beneficiary are 
                                                     father-in-law, mother-in-law, brother-in-law,     waived for a designated beneficiary with 
Form 5305-E is a model trust account                 orsister-in-law, and the spouse of any such       special needs. 
agreement that meets the requirements of             individual. A first cousin, but not his or her    Article X. Article X and any that follow may 
section 530(b)(1) and has been pre-approved          spouse, is also a “family member.”                incorporate additional provisions that are 
by the IRS. A Coverdell education savings                                                              agreed to by the grantor and trustee to 
account (ESA) is established after the form is       Responsible individual. The responsible           complete the agreement. They may include,  
fully executed by both the grantor and the           individual, generally, is a parent or guardian of 
trustee. This account must be created in the         the designated beneficiary. However, under        for example, provisions relating to: definitions, 
United States for the exclusive purpose of           certain circumstances, the responsible            investment powers, voting rights, exculpatory  
paying the qualified elementary, secondary,          individual may be the designated beneficiary.     provisions, amendment and termination, 
                                                                                                       removal of the trustee, trustee’s fees, state 
and higher education expenses of the                 Identification Numbers                            law requirements, treatment of excess 
designated beneficiary.                                                                                contributions, and prohibited transactions 
                                                     The grantor and designated beneficiary’s 
If the model account is a custodial account,         social security numbers will serve as their       with the grantor, designated beneficiary, or 
see Form 5305-EA, Coverdell Education                identification numbers. If the grantor is a       responsible individual, etc. Attach additional 
Savings Custodial Account.                           nonresident alien and does not have an            pages as necessary.
Do not file Form 5305-E with the IRS.                identification number, write “Foreign” on the     Optional provisions in Article V and Article 
Instead, the grantor must keep the completed         return for which is filed to report the grantor's VI.  Form 5305-E may be reproduced in a 
form in its records.                                 information. The designated beneficiary’s         manner that provides only those optional 
                                                     social security number is the identification      provisions offered by the trustee.
Definitions                                          number of his or  her Coverdell ESA. If the 
Trustee. The trustee must be a bank or               designated 
savings and loan association, as defined in 
                                                                                                                                        Form 5305-E (Rev. 10-2016)