Please consult your tax advisor. I have read the above and agree to the terms and limitations as shown. Each of my family’s orders will be credited to my family account as well as any additional orders specified in my family name. LAST NAME FIRST NAME EMAIL PHONE STREET ADDRESS CITY AND STATE ZIP CODE STUDENT’S LAST NAME RECEIVING CREDIT FIRST NAME(S) DISTRIBUTION OF SCRIP CREDITS (MUST CHOOSE ONE)*: SMSA TUITION BANKING OTHER TUITION BASED SCHOOL NAME *IMPORTANT: You must check this box if the distribution you have chosen this year is different than the previous year. I understand if I choose to have my child/xxxx transport my Scrip order from school that SMSA is not responsible for any Scrip which is lost, stolen or misplaced. I hereby waive any right of recovery that I may have against SMSA for Scrip which is lost, stolen or misplaced after it is given to my child/xxxx. Signature Date SMSA SCRIP TUITION CREDIT PROGRAM AGREEMENT—Part B For purchases made June 1, 2019 - May 31, 2020 (Credit School Year 2020 - 2021) RETURN ENTIRE FORM TO SMSA SCRIP OFFICE, 000 Xxxxxx Xx. K, Fond du Lac, WI 54937 ONLY FILL OUT THIS PAGE IF YOU INTEND TO SPLIT YOUR CREDIT BETWEEN MULTIPLE FAMILIES. SPLIT CREDIT INSTRUCTIONS The section labeled “tuition credited to” on the order form must be filled out with the student/family name who you wish to receive the credit. If multiple families split the credit you generate, designate your name on the order form and complete this form. The credit will be divided and allocated according to your instructions. You must also complete Part A of this form. Purchaser’s name Phone Email Credit disbursement instructions: *Family (1) Percentage of credit % *Family (2) Percentage of credit % *Family (3) Percentage of credit % *Family (4) Percentage of credit % * In order for the families to receive credit, they must have a Scrip Tuition Credit Program Agreement - Part A on file indicating their school or banking preference. Participant’s signature
