Questions? Go to or call 1-800-634-9361.
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Electronic Funds Transfer (EFT) Annuities
Use this form to set up or modify a way to transfer funds between your annuity contract and your bank account, and also to update
EFT instructions for an existing Systematic Withdrawal, Income Payments, or Annuity Builder Program. Do NOT use for non-annuity
accounts such as Fidelity IRA or Retirement Plans (Keogh). Type on screen or print out and fill in. For best results, use CAPITAL letters
and black ink. If you need more room for information or signatures, use a copy of the relevant page.
Helpful to Know
To set up or replace EFT instructions on more than one
annuity, use a separate form for each contract.
To be eligible for EFT, your account must be with an
institution that is a member of the Automated Clearing
House (ACH) and is a commercial bank, savings and
loan, or credit union. Call the institution to determine
its membership status.
A Medallion signature guarantee is required unless you
are establishing EFT for a bank account in your name
and you attach a voided check or account statement
(for checking accounts) or a deposit slip or account
statement (for savings accounts).
The table below provides important details about EFT.
Initial setup time
• 4 business days
When funds are available
Typically 4–7 business days
Maximum per transaction
$100,000 (if placed online)
Fees charged by Fidelity
• None
Fees charged by your bank
• Ask your bank
1. Contract Number/Owner(s)
Annuity Contract Number
Contract Owner Name
Joint Contract Owner Name if applicable
Evening Phone Daytime Phone Extension
2. Existing EFT Information
To delete existing instructions, check the box below or call Fidelity. If you only want to add new instructions, not delete existing instructions,
skip to Section 3.
Delete existing EFT instructions for the Contract listed in Section 1.
3. Apply EFT to Contract Payments/Program(s)
Income payments from your annuity
Systematic Withdrawal Program
Annuity Builder Program
Your annuity contract
number can be found
on a recent statement
or the portfolio positions
page on
Trust and UGMA/UTMA
Accounts: Provide names
of authorized individuals in
the Contract Owner fields.
Phone numbers will be
used if we have questions.
Select ONLY if
already established
on your contract.
Form continues on next page.
4. New EFT Information
Your annuity contract and non-annuity contract must have at least one owner’s name in common.
Bank Account
Attach voided check with
your full name preprinted on it or account
statement. Do NOT attach deposit slip.
Attach deposit slip
or account statement and provide
bank routing number.
Owner(s) Name(s) Exactly as on Bank Account
Bank Routing /ABA Number (Nine digits, starts
with 0, 1, 2, 3, or 4)
Bank Name
Checking or Savings Account Number
Fidelity Nonretirement Account
Note that distributions to a brokerage account will be deposited to the core position only.
Fidelity Nonretirement Account Number Fidelity Fund Name or Symbol Mutual fund accounts ONLY.
5. Signature and Date Form cannot be processed without signature and date of ALL contract owners.
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.
Authorize Fidelity, upon receiving instruc-
tions from you, to make payments of
amounts representing redemptions by you
or distributions payable to you by initiating
credit or debit entries to the bank account
identified in Section 2 or as indicated on
the attached account statement, voided
check, or deposit slip.
Authorize and request the bank named
above to accept such entries from Fidelity,
and to credit or debit, as indicated, your
account at the bank in accordance with
these entries without responsibility for the
appropriateness or for the existence of any
further authorization.
Acknowledge that Fidelity will not be liable
for any loss, expense, or cost arising out of
your instructions, provided that it institutes
reasonable procedures to prevent unau-
thorized transactions.
Check ONLY one.
Ask your bank for the
correct routing number.
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Signature and Date continues on next page.
Example of
account number
Example of ABA
routing number
Attach here:
If you do not attach a
voided check, a savings
deposit slip, or a bank state-
ment, you MUST obtain a
Medallion signature
guarantee in Section 5.
Did you sign the form and attach
any necessary documents? Send the
ENTIRE form and any attachments to
Fidelity Investments. You will receive
a Revised Annuity Profile.
Questions? Call 1-800-634-9361.
Regular Mail
Except NY Regular Mail NY only Overnight Mail
Annuity Service Center
P.O. Box 770001
Cincinnati, OH 45277-0050
Annuity Service Center
P.O. Box 770001
Cincinnati, OH 45277-0051
Fidelity Investments
100 Crosby Parkway, KC2Q
Covington, KY 41015
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. Other insurance products available at Fidelity are issued by third-party insurance compa-
nies, which are not affiliated with any Fidelity Investments company. A contract’s financial guarantees are
subject to the claims-paying ability of the issuing insurance company.
Fidelity Brokerage Services LLC, Member NYSE, SIPC 611915.8.0 (02/16)
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Who must sign?
• Owner of Contract
Joint Owner of Contract (if jointly held)
All Trustees (if trust owned)
Custodian (if UGMA)
Do I need a Medallion signature guarantee?
ONLY if you requested EFT for a bank account and did not attach:
For a checking account: a voided check or account statement with your name preprinted on it
For a savings account: a deposit slip or an account statement with your name preprinted on it
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 signature guarantee.
You can have the form authenticated at a Fidelity Investor Center if all signers are present.
Print Owner Name
Owner Signature Date MM DD YYYY
Print Joint Owner Name
Joint Owner Signature Date MM DD YYYY
Individual providing signature guarantee Providing this information will avoid delay or rejection of your request.
Guarantor Name Phone Extension
5. Signature and Date, continued