6. Signature and Date ALL contract owners must sign and date.
By signing below, you:
• Authorize and request Fidelity Investments
Life Insurance Company to make the with-
drawals indicated on this form from the
contract listed In Section 1.
• Acknowledge that withdrawals will be taxed
as ordinary income, and may be subject
to a 10% early withdrawal penalty if taken
before age 59½.
• Indemnify Fidelity and its agents, affiliates,
successors, and employees from any liabil-
ity in the event that you fail to meet the
IRS requirements.
• Authorize and request Fidelity Investments
Life Insurance Company to make the with-
drawals indicated on this form from the
contract listed In Section 1.
• Agree that if you withdraw all or part of the
variable portion of your contract after your
first annuity income date but on or before
its fifth anniversary, you will forfeit the por-
tion of your purchase payment intended to
provide annuity income to annuitants still
living after the withdrawal period.
• Acknowledge that if any portion of this
contract was funded via a partial exchange
of an existing annuity contract within the
last 6 months, any withdrawals from the
existing or new contract that are not part
of an annuity income program could nullify
the partial 1035 protection or result in an
adverse tax consequence.
• Certify under penalties of perjury that
you are U.S. citizen or other U.S. person
(including a resident alien individual) and
that the tax ID you provided on the Fidelity
Annuity Contract associated with
this withdrawal (or as updated in a subse-
quent communication to Fidelity) is your
correct tax identification number.
Customers surrendering contracts
• Understand that Fidelity will be released
from any other contractual obligation and
that the contract listed in Section 1 will
be canceled.
• Certify that there are no existing assign-
ments and that no bankruptcy petition has
been filed by or against you.
Customers requesting EFTs
• Authorize and request Fidelity to make
EFT withdrawals from the contract listed
in Section 1 by initiating debit entries to
that contract.
A Medallion signature guarantee is required next to each signature below if:
• Your withdrawal amount is over
$100,000.
• Withdrawals are sent to someone other
than the account owner.
• Contract’s address of record has been
changed within the past 10 days AND
the withdrawal amount is over $10,000.
You can get one from most banks, credit unions, and other financial institutions. A notary seal/stamp is NOT a signature guarantee.
Print Contract Owner Name
Date MM DD YYYY
DATE
Owner Signature
SIGN
Print Joint Contract Owner Name
Date MM DD YYYY
DATE
Owner Signature
SIGN
Individual providing signature guarantee Providing this information will avoid delay or rejection of your request.
Guarantor Name Phone Extension
1.804453.115 Page 3 of 3 021390403
Fidelity insurance products are issued by Fidelity Investments Life Insurance Company (FILI), and, in New
York, by Empire Fidelity Investments Life Insurance Company
®
, New York, N.Y. FILI is licensed in all states
except New York. A contract’s financial guarantees are subject to the claims-paying ability of the issuing
insurance company.
Fidelity Brokerage Services LLC, Member NYSE, SIPC. 494734.15.0 (12/17)
Did you sign the form? Send the ENTIRE
form to Fidelity.
Questions? Call 1-800-634-9361.
Regular Mail
Except NY Regular Mail NY only Overnight Mail
Annuity Service Center
PO Box 770001
Cincinnati, OH 45277-0050
Annuity Service Center
PO Box 770001
Cincinnati, OH 45277-0051
Fidelity Investments
100 Crosby Parkway, KC2Q
Covington, KY 41015
MEDALLION SIGNATURE GUARANTEE
MEDALLION SIGNATURE GUARANTEE
