Fillable Able Rollover ABLE Rollover Form (Fidelity Investments)

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Able Rollover ABLE Rollover Form (Fidelity Investments)

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1.9880128.102 036450201
Page 1 of 6
Questions? Go to Fidelity.com/ABLE or call 844-458-2253.
Rollover/Transfer Request — ABLE Account
Use this form to initiate a rollover or program-to-program transfer of ABLE or 529 assets to an ABLE account at Fidelity. Do NOT use this
form to change the beneficiary on your ABLE account. Go to Fidelity.com/forms to download the Beneficiary Change — ABLE Account
form. Type on screen or fill in using CAPITAL letters and black ink. If you need more room for information, make a copy of the relevant page.
Helpful to Know
• According to IRS regulations, you are eligible to roll
over or complete a program-to-program transfer into
another ABLE account once every 12 months without
changing the beneficiary. To be valid, a rollover to
the ABLE account must be made within 60 days of
the distribution from the other account.
• Submit this form directly to Fidelity, not to the ABLE
or 529 account administrator from which you are
requesting the funds to be transferred.
• If you are rolling over or transferring an ABLE or 529
account, it is necessary to establish an ABLE account
at Fidelity first. If you do not have an ABLE account at
Fidelity for the Designated Beneficiary, you must go to
Fidelity.com/ABLE to open a new Fidelity ABLE account
prior to submitting this form.
• Your current account administrator may require specific
forms or signatures to roll over or transfer your account
assets to Fidelity. The administrator may also send you a
rollover check directly. Check with your current account
administrator to verify requirements.
• If you are rolling over from a non-Fidelity ABLE account
and do not have a check yet, Fidelity will contact the
ABLE account administrator and initiate a full liquidation
and transfer of the ABLE assets directly to us. Fidelity
is not responsible for market fluctuation on requests
with written liquidation instructions.
• If you are rolling over from a non-Fidelity 529 account
and do not have a check yet, Fidelity will contact the
529 plan administrator and instruct it to liquidate and
transfer the funds per your instructions in Section 5
of this form and direct the proceeds to us. The non-
Fidelity 529 must be either an individual or joint 529.
Fidelity is not responsible for market fluctuation on
requests with written liquidation instructions.
• Per IRS regulations, a principal and earnings statement
must be provided with a 529-to-ABLE or ABLE-to-ABLE
rollover. Until we receive the principal and earnings
breakdown, we are required to treat the entire rollover
amount as earnings in the account.
• The IRS considers rollovers from a 529 to an ABLE to
be contributions to the ABLE account. Therefore, any
amount rolled from a 529 to an ABLE account cannot
exceed the maximum annual contribution amount
eligible for the year in which the rollover is taking
place. Also, the combination of your contributions plus
529-to-ABLE rollovers cannot exceed the maximum
annual contribution amount allowable to an ABLE
account for any given year.
• Any assets rolled over or transferred in will be invested
according to the allocation instructions on file for your
Fidelity ABLE account.
• If there is a Person with Signature Authority (PSA)
established on this account, the PSA must sign this
form. Otherwise, the Designated Beneficiary/Eligible
Individual must sign in Section 6a.
1. ABLE Account Information
Fidelity Account Number
Designated Beneficiary/Eligible Individual Name Social Security or Taxpayer ID Number
Person with Signature Authority (PSA) Name If applicable Social Security or Taxpayer ID Number
Daytime Phone Extension
Phone number will be
used if we have questions,
but will not be used to
update your Fidelity
contact information.
Form continues on next page.
Print
Reset
Save
2. 60-Day Rollover Complete only if you have received a check to include with this form.
Indicate below if this is a rollover from a non-Fidelity ABLE or 529 account. Please note: According to IRS regulations, you are only eligible to
roll over or transfer into an ABLE account once every 12 months without changing the beneficiary.
Important: You must also provide a statement issued by the distributing ABLE or 529 account showing the earnings portion of the distribution,
so that your principal and earnings amounts are appropriately recorded. Until such time as Fidelity receives the specified documentation, we
must, by law, treat the entire amount of the contribution as earnings in the ABLE or 529 account receiving the distribution.
60-Day Rollover from a non-Fidelity ABLE account
Check this box and skip to Section 6.
60-Day Rollover from a non-Fidelity 529 account
Check this box and skip to Section 6.
3. Program-to-Program Transfer from an ABLE Account Not Administered
by Fidelity
Applicable for ABLE-to-ABLE transfers ONLY.
Complete this section if you are requesting Fidelity to initiate a FULL liquidation and transfer of the entire ABLE account from your
current ABLE account administrator. As part of the transfer process, Fidelity will request the additional required principal and earnings
documentation from your current ABLE account administrator on your behalf. Until we receive the principal and earnings documentation,
we are required to treat the entire rollover amount as earnings in the account. Please note: According to IRS regulations, you are only
eligible to roll over or transfer an ABLE account once every 12 months without changing the beneficiary.
For a transfer from a non-Fidelity 529 account, do NOT complete this section. You must either complete Section 2 and submit a
check with this form, or complete Section 5.
Transferring Account Information Only required for a Program-to-Program Transfer
Designated Beneficiary/Eligible Individual Name Social Security or Taxpayer ID Number
Person with Signature Authority (PSA) Name if applicable Social Security or Taxpayer ID Number
Transferring Firm Information Only required for a Program-to-Program Transfer
Transferring Account Number
Transferring Firm Name
Contact Person
Daytime Phone Extension
Transferring Firm Address
City State ZIP Code
Check ONLY one.
Page 2 of 6
1.9880128.102 036450202
Form continues on next page.
Page 3 of 6
1.9880128.102 036450203
4. Rollover from a Fidelity 529 Account Applicable for individual 529 transfers ONLY.
Complete this section if you are rolling assets from a Fidelity 529 account to your ABLE account. According to IRS regulations, you are only
eligible to roll over or transfer to an ABLE account once every 12 months without changing the beneficiary. The rollover amount cannot
exceed the maximum annual contribution amount allowed to an ABLE account for the year. The combination of contributions plus your
rollover amount cannot exceed the maximum annual contribution amount allowed to an ABLE account for the year.
Fidelity 529 Account Number 529 Beneficiary Name
ALL assets in this account. Default if no other information indicated below.
Skip to Section 6.
ONLY the following amount(s) from the following portfolio(s).
Portfolio Dollar Amount
or ALL
$
Portfolio Dollar Amount
or ALL
$
Portfolio Dollar Amount
or ALL
$
Total Dollar Amount
$
5. Rollover of Assets from a 529 Plan Not Administered by Fidelity
Applicable for individual or joint 529-ABLE transfers ONLY.
Complete this section if you are requesting Fidelity to initiate a liquidation and transfer of your 529 account from your current 529 account
administrator based on the instructions below. As part of the transfer process, Fidelity will request the additional required principal and earn-
ings documentation from your current 529 account administrator on your behalf. Until we receive the principal and earnings documentation,
we are required to treat the entire rollover amount as earnings in the account. Please note: According to IRS regulations, you are only eligible
to roll over or transfer to an ABLE account once every 12 months without changing the beneficiary.
Transferring Account Information
Individual
Joint
Other
529 Participant Name Social Security or Taxpayer ID Number
Joint 529 Participant Name If applicable Social Security or Taxpayer ID Number
529 Beneficiary Name Social Security or Taxpayer ID Number
529 Beneficiary Relationship to the ABLE Designated Beneficiary/Eligible Individual Required only if NOT the same individual.
Indicate at least one
portfolio name. If the
amount of your request
is equal to or greater
than your portfolio
value, we will send only
the available balance.
Check the type of
529 account you
are requesting to
transfer to Fidelity.
Rollover of Assets from a 529 Plan Not Administered by Fidelity continues on next page.
0.00
Page 4 of 6
1.9880128.102 036450204
Transferring Firm Information
529 Account Number
Transferring Firm Name
Contact Person
Daytime Phone Extension
Transferring Firm Address
City State ZIP Code
Transfer Instructions
The rollover amount cannot exceed the maximum annual contribution amount allowed to an ABLE account for the
year. The combination of contributions plus your rollover amount cannot exceed the maximum annual contribution
amount allowed to an ABLE account for the year.
Full Liquidation — Liquidate and transfer my entire account.
Skip to Section 6.
Partial Liquidation — Liquidate and transfer only a part of my account, as detailed below:
Total Amount
$
.
Portfolio Name Dollar Amount
OR
Full Portfolio
Distribution
$
.
Portfolio Name Dollar Amount
OR
Full Portfolio
Distribution
$
.
Portfolio Name Dollar Amount
OR
Full Portfolio
Distribution
$
.
Portfolio Name Dollar Amount
OR
Full Portfolio
Distribution
$
.
Note: If you are
requesting a transfer
from a Coverdell
education savings
account, you may
need to contact
the transferring
firm to request a
liquidation.
Check only one.
Attach extra sheets
for additional
portfolio listings.
Form continues on next page.
5. Rollover of Assets from a 529 Plan Not Administered by Fidelity, continued
Page 5 of 6
1.9880128.102 036450205
6. Signature(s) and Date(s) ALL required signers must sign and date below.
Please review the signature requirements.
Who must sign?
• The PSA must sign and date in 6a. If there is not a PSA, the Designated Beneficiary/Eligible Individual must sign.
• If you are requesting a transfer from either a Fidelity or non-Fidelity 529 account, all Participants of the 529 must sign in 6b.
By signing below, you:
• Certify that you have read, understand,
and agree to the terms in the ABLE
Plan Disclosure Document, Participation
Agreement, and Customer Agreement.
• Authorize and request Fidelity and its affili-
ates, agents, and employees to execute the
instructions you have provided above.
• Accept full responsibility for complying with
IRS requirements for ABLE rollovers and
program-to-program transfers and indemnify
Fidelity and its affiliates, agents, and
employees from any liability in the event you
fail to comply with any IRS requirements.
• Acknowledge that pursuant to federal law,
you may only have one ABLE account per
beneficiary.
• Understand that federal law allows one
rollover per Designated Beneficiary during
a 12-month period without changing the
Designated Beneficiary.
• Acknowledge that pursuant to federal
law, a rollover from one ABLE account to
another ABLE account must be completed
within 60 days of the date of the distribu-
tion; otherwise, the distribution will be
subject to federal income taxes and a
federal penalty tax.
• Per IRS regulations, a principal and
earnings statement must be provided with
a 529-to-ABLE or ABLE-to-ABLE rollover.
Until we receive the principal and earnings
breakdown, we are required to treat the
entire rollover amount as earnings in
the account.
6a. PSA or Designated Beneficiary/Eligible Individual
PRINT PSA OR DESIGNATED BENEFICIARY/ELIGIBLE INDIVIDUAL NAME
MEDALLION SIGNATURE GUARANTEE
PSA OR DESIGNATED BENEFICIARY/ELIGIBLE INDIVIDUAL SIGNATURE
SIGN
X
TODAY’S DATE MM/DD/YYYY
DATE
X
6b. 529 Participant(s)
A Medallion signature guarantee is required if:
• the participant of the Fidelity 529 is different than the individual signing above in 6a
AND
• the value of the transfer is greater than $10,000.
If the form is completed at a Fidelity Investor Center, the Medallion signature guarantee is not required. You can get a Medallion signature
guarantee from most banks, credit unions, and other financial institutions. A notary seal/stamp is NOT a Medallion signature guarantee.
PRINT PARTICIPANT NAME
MEDALLION SIGNATURE GUARANTEE
PARTICIPANT SIGNATURE
SIGN
X
TODAY’S DATE MM/DD/YYYY
DATE
X
Signature(s) and Date(s) continues on next page.
Page 6 of 6
1.9880128.102 036450206
PRINT PARTICIPANT NAME
MEDALLION SIGNATURE GUARANTEE
PARTICIPANT SIGNATURE
SIGN
X
TODAY’S DATE MM/DD/YYYY
DATE
X
Delivering Firm Use Only
To the previous trustee or custodian: Please be advised that Fidelity Brokerage Services LLC has established an ABLE account to receive the
distribution from the ABLE account referenced in Section 3, or the 529 account referenced in Section 5, as applicable. Fidelity Brokerage
Services LLC will accept the proceeds from the account you administer and place the proceeds in an account that will hold units of interest
in a Fidelity-managed ABLE account. Please provide documentation so that principal and earnings amounts are appropriately recorded.
Successor Custodian/Trustee Signature
On this form, “Fidelity” means Fidelity Brokerage Services LLC and its affiliates. Brokerage services are
provided by Fidelity Brokerage Services LLC, Member NYSE, SIPC. 779044.3.0 (09/18)
Did you sign the form? Send the ENTIRE form and any required
documents to Fidelity Investments.
Questions? Go to Fidelity.com/ABLE or call 844-458-2253.
Make checks payable to: Fidelity Brokerage Services LLC
Use the postage-paid envelope, drop off at a Fidelity
Investor Center, OR deliver to:
Regular mail
Fidelity Investments
P.O. Box 770001
Cincinnati, OH 45277-0037
Overnight mail
Fidelity Investments
100 Crosby Parkway KC1K
Covington, KY 41015
6. Signature(s) and Date(s), continued
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Able Rollover ABLE Rollover Form (Fidelity Investments)

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Completed 15 July 2020

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