6. Signature and Date Form cannot be processed without signature and date of ALL contract owners.
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.
• Acknowledge, 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 exist-
ing 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.
Who must sign?
• Owner of Contract
• Joint Owner of Contract (if jointly held) You can access a recent quarterly statement to confirm ownership.
• All Trustees (if trust owned)
• Custodian (if UGMA)
• Please note: Original “ink” signatures are required. Copies are not accepted.
Do I need a Medallion Signature Guarantee?
• YES — If the withdrawal meets one or more of these criteria, the Medallion Signature Guarantee is required next to each signature:
– The value of the withdrawal is over $100,000.
– The withdrawal is being sent to anyone other than the owners listed in Section 1.
– The address of record on the contract has been changed within the past 10 days AND the value of the withdrawal is over $10,000.
Where can I get a Medallion Signature Guarantee?
• You can get one at most banks, credit unions, and other financial institutions. A notary seal is not a Medallion Signature Guarantee.
• You can have the form authenticated at a Fidelity Investor Center if all signers are present.
Print Owner/Authorized Individual Name
MEDALLION SIGNATURE GUARANTEE
Owner/Authorized Individual Signature Date MM DD YYYY
SIGN
X
Print Joint Owner/Authorized Individual Name
MEDALLION SIGNATURE GUARANTEE
Joint Owner/Authorized Individual Signature Date MM DD YYYY
SIGN
X
Individual providing Medallion Signature Guarantee Providing this information will avoid delay or rejection of your request.
Guarantor Name Phone Extension
1.812957.118 Page 3 of 4 010900403
