Fillable Address-change /BOSTON/xinet/ Bos Work/ Jobs/34761/PIECE13/113448 01 Frm Address Ch (Fidelity Investments)

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Address-change /BOSTON/xinet/ Bos Work/ Jobs/34761/PIECE13/113448 01 Frm Address Ch (Fidelity Investments)

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Questions? Go to Fidelity.com/address or call 800-343-3548.
1.926101.101 Page 1 of 2 025830101
Address Change
Use this form to update the address or phone of an owner or authorized individual. Type on screen or fill in using CAPITAL letters and
black ink. If you need more room for check requests, make a copy of the relevant page.
Helpful To Know
• You must already be an owner or an authorized
individual (trustee, custodian, etc.) in order to change
an address on an account.
• If your statements show accounts of other owners, ALL
of those owners must sign this form. To “unbundle” a
statement group, contact Fidelity.
• You can change your address at Fidelity.com/address and
your combined statement address at Fidelity.com/statement.
• To change your address on employer-sponsored accounts,
call your plan sponsor or go to Netbenefits.fidelity.com.
• To request duplicate statements, or to change the address
for them, you must complete the Duplicate Statements
Request form.
1. Account Owner(s)
Name
Additional Owner/Authorized Individual Name
2. Accounts Involved Change of address will be applied only to the account(s) indicated.
ALL accounts associated with:
Social Security or Taxpayer ID Number
Social Security or Taxpayer ID Number
Do NOT update any Fidelity
life insurance contracts.
ONLY on these accounts:
Account Number
Account Number Account Number
Account Number
Account Number Account Number
Account Number
Account Number Account Number
Do NOT update any Fidelity life insurance contracts.
3. New Address of Owner(s)
Legal/Residential Address This is your legal address used for tax reporting.
Address
City State/Province ZIP/Postal Code Country
Daytime Phone Extension
Mailing Address This may be a P.O. Box, drop box, or c/o location.
Same as legal/residential address
Address
City State/Province ZIP/Postal Code Country
Louisiana Residents:
Consult a legal or tax
professional before
changing address on
joint accounts.
If you check this
box, the address
will remain
unchanged on
any accounts
you do not
identify here.
Form continues on next page.
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On this form, “Fidelity” means Fidelity Brokerage Services LLC and its affiliates. Brokerage services are
provided by Fidelity Brokerage Services LLC, Member NYSE, SIPC. 575108.4.0 (02/18)
1.926101.101 Page 2 of 2 025830102
4. New Address of Additional Owner/Authorized Individual
Complete this section ONLY if a joint owner/authorized individual has a separate address. This individual must already be an owner or
authorized on the account.
Additional Owner/Authorized Individual
Legal/Residential Address This is your legal address used for tax reporting.
Address
City State/Province ZIP/Postal Code Country
Daytime Phone Extension
Mailing Address This may be a P.O. Box, drop box, or c/o location.
Same as legal/residential address
Address
City State/Province ZIP/Postal Code Country
5. Signatures and Dates
By signing below, you:
• Authorize Fidelity to act on all instructions given on this form.
• Accept all terms and conditions described in this form.
• Certify that all information you provided is correct to the best of your knowledge.
One owner signature is required unless you have a Mutual Fund Account (the account number begins with a 2 followed by two
letters), in which case all owners must sign.
PRINT OWNER NAME
OWNER SIGNATURE DATE MM/DD/YYYY
SIGN
X X
PRINT OWNER/AUTHORIZED INDIVIDUAL NAME
OWNER/AUTHORIZED INDIVIDUAL SIGNATURE DATE MM/DD/YYYY
SIGN
X X
Did you print and sign the form? Send the form to Fidelity.
Fidelity will send a confirmation to your new address.
Questions? Go to Fidelity.com/address or call 800-343-3548.
Use the postage-paid envelope OR deliver to:
Regular mail
Fidelity Investments
P.O. Box 770001
Cincinnati, OH 45277-0002
Overnight mail
Fidelity Investments
100 Crosby Parkway KC1K
Covington, KY 41015
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Completed 16 July 2020

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