Fillable Automatic Investments Mrd Life Expectancy (Fidelity Investments)

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Automatic Investments Mrd Life Expectancy (Fidelity Investments)

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Page 1 of 5
Questions? Go to Fidelity.com/rmd or call 800-343-3548.
Automatic Withdrawals — RMD/Life Expectancy
Use this form to request Fidelity to calculate and establish an automatic required minimum distribution (RMD) or life expectancy plan
for a Traditional, Rollover, Roth, SEP, or SIMPLE IRA on an ongoing basis. Do NOT use this form for Fidelity Retirement Plan accounts,
Inherited IRAs, or annuities. Not available to nonresident aliens due to tax-withholding requirements. Type on screen or fill in using
CAPITAL letters using black ink. If you need more room for information or signatures, make a copy of the relevant page.
Helpful to Know
• It is your responsibility to ensure that your withdrawals
comply with IRS rules and deadlines for RMDs. You may
want to consult a tax advisor.
– For anyone who reached age 70½ in 2019 or before,
RMDs are required to begin on or before April 1 of
the year after reaching age 70½, and must be taken
annually by each December 31 thereafter.
– Due to passage of the SECURE Act legislation, for
those turning 70½ in 2020 or after, the RMD age
has been increased to 72. RMDs are now required
to begin on or before April 1 of the year after reach-
ing age 72, and must be taken annually by each
December 31 thereafter.
• Use this form only if you want Fidelity to calculate and
distribute your RMDs or life expectancy withdrawals. If
you want a specific amount distributed, use the Automatic
Withdrawals — IRA form.
• For mutual funds, note that:
– Withdrawals could trigger redemption or transaction
fees (see the applicable fund prospectus).
– If a fund is closed to new investors, you will not be
able to purchase new shares of the fund in the future
if you draw your fund balance down to zero.
• If you want to draw against the value of individual secu-
rities, ETFs, and certain noneligible mutual funds (such
as closed-end funds), you must sell them in advance and
withdraw them as cash.
• You must be at least 59½ to set up an automated with-
drawal plan using this form. If you are not yet required to
take RMDs and are establishing a life expectancy plan for
your non-Roth IRA, it will be recalculated and converted
to an RMD plan when you reach the applicable RMD age.
• Only life expectancy plans are available for Roth IRAs
because RMDs are not required during the lifetime of the
original owner.
• For tax reasons, if you have both Roth and non-Roth
IRAs, you must complete a separate form for each type.
• Your RMD is calculated using all the Fidelity IRA accounts
you indicate in Section 3 (not including Roth or Inherited
IRAs). RMDs for any non-Fidelity IRAs must be calculated
separately. RMD amounts are generally calculated using
the Uniform Lifetime Table (which applies a standard
joint life expectancy factor based on your age). The one
exception applies if your sole primary beneficiary is your
spouse and he or she is more than 10 years younger than
you. If so, the Spousal Exception Joint Life Expectancy
Table is used (which applies a joint life expectancy factor
based on both your age and your spouse’s age, which
will generally result in a lower RMD amount). Both IRS
tables are available online at Fidelity.com.
• At the beginning of each year, Fidelity determines which
IRS table to apply for each indicated IRA based on bene-
ficiary designations on file at that time. Important: Keep
your beneficiary information current to help ensure
that proper calculations are performed. Fidelity will
not automatically update your RMD plan until January
of the year following the year in which you make a ben-
eficiary change. Note that IRS rules generally permit the
Spousal Exception Table to be used only if your spouse
is the sole primary beneficiary for the entire year.
Because of this, it may be necessary for you to take an
additional withdrawal to satisfy your RMD in the year
of a beneficiary change. Please consult your tax advisor
to determine how a beneficiary change may affect your
individual situation.
1. Account Owner
Name Social Security or Taxpayer ID Number
Type of Account(s) Included
Non-Roth IRA(s) (such as Traditional, Rollover, SEP, and SIMPLE IRAs)
Default if no choice indicated, unless you have only Roth IRAs, in which case that will be the default.
Roth IRA(s) (life expectancy plan) RMDs are not required for Roth IRAs during the lifetime of the original owner.
Check only one.
1.931222.113 007321701
Form continues on next page.
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Page 2 of 5
2. Request Type
ESTABLISH a new automatic withdrawal plan
CHANGE an existing automatic withdrawal plan
Account Number Type of Plan RMD or Life Expectancy
DELETE an existing automatic withdrawal plan
Skip to Section 8.
Account Number Type of Plan RMD or Life Expectancy
3. Calculating Your Distribution Amounts
Accounts you identify in this section will be used ONLY to calculate distribution amounts. Distributions will be withdrawn from the account(s)
you identify in Section 5.
Account(s) Included in Calculation
Indicate which account(s) Fidelity should use to calculate your distributions. Fidelity will use the prior year’s 12/31 market value for these
accounts. If there are adjustments to those amounts, indicate them in the “Calculation Adjustments” section.
All Roth or non-Roth (as indicated in Section 1) Fidelity IRAs under your Social Security number
ONLY the following Fidelity IRA(s):
Account Number Account Number Account Number
Calculation Adjustments
Provide the 12/31 market value of any IRA assets that were in the process of being recharacterized, transferred,
or rolled over to the above IRAs last year, but were not included in last year’s 12/31 market value as reported
by Fidelity:
Amount
$
Reduce this year’s automatic distribution amount by the amount of the distributions already made this year, as
indicated below:
Amount
$
Additional Distribution Amount
Optional. Skip to Section 4 if you do not want to take out more than your RMD or life expectancy amount.
Additional amount per year
$
Add for this year only
Default if no choice indicated.
Add for this year and future years
4. Distribution Schedule
Distribution payments may be made earlier or later depending on market availability. Examples include payments that are scheduled for a
day when the stock market is closed or for a day that doesn’t exist in every month (29th–31st), or payments scheduled close to the begin-
ning or end of the year.
Ongoing RMDs or Life Expectancy Distributions
If you begin withdrawals midyear, your entire RMD or life expectancy distribution for the current year will be paid out evenly over the
remaining number of scheduled payments for the year. For custom frequency options, go to Fidelity.com/updateaccountfeatures or call
Fidelity. If no frequency is indicated, you will receive annual distributions on the 5th of every December.
Annually
Quarterly
Monthly
Start Date MM DD YYYY
Complete ONLY if
one or both of these
adjustment circum-
stances apply.
Provide amount and
check one option.
1.931222.113 007321702
Check ONLY one and
provide start date.
Do not mix Roth and
non-Roth accounts.
Distribution Schedule continues on next page.
If you check this box,
provide ONLY the infor-
mation that is changing.
Check only one.
Page 3 of 5
1.931222.113 007321703
First-Year RMD
Optional. Not applicable to Roth IRA life expectancy distributions. For the year in which you reach RMD age, you may defer your first RMD
until April 1 of the following year. If you are choosing this option for your RMD plan, please make sure the start date above in Ongoing
RMDs is a date after the date you indicate in this section. You may want to consult a tax advisor.
If you turned 70½ in 2019, defer LAST year’s RMD until this date:
Date must be on or before April 1 of THIS year.
Date of Deferred First RMD MM DD YYYY
5. Funding Your Distributions
Distributions will be withdrawn from the account(s) and, if applicable, the Eligible Positions, you identify below. Eligible Positions
include your core position (for brokerage IRAs), all Fidelity mutual funds, and those non-Fidelity mutual funds available through Fidelity
FundsNetwork where the mutual fund company has agreed to make the fund available for automatic distributions. You can specify that
the distributions come from any or all of the accounts identified in Section 3. If your distributions are ONLY from one Fidelity managed
account, skip to Section 6.
Proportional Distributions
Distribute proportionally from all Eligible Positions across ALL the accounts in Section 3
Default if no choice indicated.
Distribute proportionally ONLY from all Eligible Positions from the following Fidelity IRA accounts:
IRA Account Number IRA Account Number IRA Account Number
Fixed-Percentage Distributions
Liquidate and distribute ONLY from these positions within the indicated IRAs and in the percentages listed:
IRA Account Number Core Position or Fund Name / Number Percentage
.0%
IRA Account Number Core Position or Fund Name / Number Percentage
.0%
IRA Account Number Core Position or Fund Name / Number Percentage
.0%
IRA Account Number Core Position or Fund Name / Number Percentage
.0%
IRA Account Number Core Position or Fund Name / Number Percentage
.0%
Total
must add up to 100%.
.0%
Secondary withdrawal instructions for fixed-percentage distributions:
For fixed-percentage distributions ONLY. Will be used if there are insufficient funds in the above core position(s) or fund name(s)/
number(s); and will be distributed from any Eligible Positions with the lowest value to the highest value.
Any core position, and then any non-core money market position(s)
Any core position, then any non-core money market position(s), and then any other mutual fund position(s)
Default if no choice indicated.
Check one
distribution option,
either a propor-
tional option or the
fixed-percentage
option.
NOT available for
Fidelity managed
accounts.
For any Fidelity managed
accounts, list the account
number only, not fund
names or percentages
(Fidelity managed
accounts are kept in
proportion as indicated in
each account).
Form continues on next page.
4. Distribution Schedule, continued
0
0073217041.931222.113
Page 4 of 5
6. Distribution Method
You must obtain a Medallion signature guarantee in Section 8 if establishing EFT instructions for a bank account that is not in your name, or if
directing to a Fidelity account of which you are not the owner.
Directly deposited into a Fidelity nonretirement brokerage account. Deposits will be made to the core position.
Requires a Medallion signature guarantee if going to an account of which you are not the owner.
Fidelity Nonretirement Account Number
Directly deposited into a Fidelity nonretirement mutual fund account. Account consists of a combination of nine num-
bers and letters (example: 2AB-123456).
Fidelity Nonretirement Account Number Fidelity Fund Name or Symbol Mutual fund accounts ONLY.
Electronic funds transfer (EFT) to a bank or credit union account. To add EFT to an account, go to Fidelity.com/eft or
provide your bank information below.
If EFT cannot be established for any reason, a check will be sent to your address of record.
A. EFT to your bank account. You must be an owner on the Fidelity account and the bank account. Provide
your account information below. You must attach a voided check, deposit slip, or bank statement with
the account number and all owner names preprinted on it.
Checking Savings
B. 3rd Party EFT to someone else. (Available for brokerage accounts only.) The names on the bank account
and the Fidelity account are different. This option ONLY allows you to move money TO the outside account
and may not be used to make transfers for commercial purposes. Provide the account information below.
A Medallion signature guarantee is required in Section 8.
Owner(s) Name(s) Exactly as on Bank Account
Bank Routing/ABA Number Bank Name
Checking or Savings Account Number
Check mailed to the address of record
Default if no choice indicated or if we are unable to process your choice.
7. Tax Withholding
Automatic withdrawals from your non-Roth IRA are subject to federal and, where applicable, state income tax withholding unless you elect not to
have withholding apply below (if you are a U.S. citizen or other U.S. person, including a resident alien individual). If you do not elect out of with-
holding, federal income tax will be withheld at the rate of 10% from your total IRA distribution amount, unless you indicate a higher percentage
below. If you made nondeductible contributions to your IRA, this may result in excess withholding from your distributions. If you elect not to have
withholding apply to your distributions or if you do not have enough federal income tax withheld from your distribution, you may be responsible
for payment of estimated tax. You may incur penalties under the estimated tax rules if your withholding and estimated tax payments are not suffi-
cient. Withholding instructions provided will remain effective for all automatic withdrawals until you either revoke them or give us new instructions.
See “State Tax Withholding — IRA Withdrawals” at the end of this form.
Federal
Do NOT withhold federal taxes
Withhold federal taxes at the rate of:
Percentage
Minimum 10%; maximum 99%. Whole
numbers; no dollar amounts. Note that
if there is federal tax withholding, certain
states require that there also be state tax
withholding.
%
State
Do NOT withhold state taxes unless required by law
Withhold state taxes at the applicable rate
Withhold state taxes at the rate of:
Percentage
Maximum 99%. Whole numbers;
no dollar amounts.
%
Check one and
provide any required
information.
If you ONLY have
one set of EFT
instructions already
established for the
account(s) referenced
in Section 5, check
the box and skip to
Section 7. Otherwise,
complete the entire
section.
Provide bank
information ONLY if
establishing new EFT
instructions OR if you
have multiple EFT
instructions available
for the account(s)
referenced in Section 5.
Check one in each
column. IRA owner’s
legal/residential
address determines
which state’s tax
rules apply.
Form continues on next page.
On this form, “Fidelity” means Fidelity Brokerage Services LLC and its affiliates. Brokerage services are
provided by Fidelity Brokerage Services LLC, Member NYSE, SIPC. 589821.15.0 (01/20)
1.931222.113
Page 5 of 5
007321705
8. Signature and Date
By signing below, you:
• Authorize and request the custodian for
the Fidelity IRA, Fidelity Management
Trust Company and its agents, affiliates,
employees, or successor custodians (Fidelity),
to withdraw your RMD or life expectancy
payments for the IRA account(s) indicated in
Section 5, as indicated in this form.
• Acknowledge that non-Roth IRA withdraw-
als will be taxed as ordinary income, and
may be subject to a 10% early withdrawal
penalty if taken before age 59½.
• Acknowledge that withdrawals made from
any SIMPLE IRA prior to age 59½ and
within the first two years of participating
in an employer’s SIMPLE IRA plan may be
subject to a 25% early withdrawal penalty.
• Accept full responsibility for withdrawing
the RMD from your Traditional, Rollover,
SEP, or SIMPLE IRA, in accordance with
applicable IRS rules.
• Indemnify Fidelity from any liability in
the event that you fail to meet the IRS
requirements.
Customers requesting EFT:
• Authorize and request Fidelity to make EFT
distributions from the Fidelity IRA(s) listed
in this form by initiating debit entries to
such Fidelity IRA(s).
• Authorize us, upon receiving instructions
from you or as otherwise authorized by you,
to make payments from you and to you or
to your designee, by credit or debit entries
to the designated account at the financial
institution named in this form or the finan-
cial institution specified in your existing
instructions (the “Bank”). You authorize
the Bank to process such entries and to
credit or debit the designated account at
that Bank for such entries. You ratify such
instructions and agree that neither we nor
any mutual fund will be liable for any loss,
liability, cost, or expense for acting upon all
such instructions believed to be genuine if
we employ reasonable procedures to pre-
vent unauthorized transactions. You agree
that this authorization may only be revoked
by written notice to us in such time and
manner as to afford us and the Bank a rea-
sonable opportunity to act upon it.
• Warrant and represent that (i) the third par-
ty’s account identified in Section 6 is owned
by a natural person, (ii) that person has
authorized his/her account to be credited
in accordance with your instructions, and
(iii) the account has been established for
personal, family, or household use, and not
for commercial purposes.
• Understand that Fidelity may purge unused
EFT instructions from your account(s) on a
periodic basis without notice to you.
• Understand that Fidelity may terminate the
EFT instructions from your account(s) at any
time in its sole discretion.
For Connecticut Residents:
• Acknowledge that, as a resident of CT, your
distributions from retirement accounts are
subject to the highest marginal tax rate. If
you are exempt from state tax, you have
the option to elect out of state tax with-
holding. Otherwise, penalties may apply.
The penalty for reporting false information
is a fine of not more than $5,000, imprison-
ment for not more than five years, or both.
• Confirm that your state tax withholding
election is true, complete, and correct.
A Medallion signature guarantee is required:
• to establish EFT instructions for an account of which you are not an owner.
• if the withdrawals are going to a Fidelity account with no common owner.
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 OWNER NAME
MEDALLION SIGNATURE GUARANTEE
OWNER SIGNATURE
SIGN
X
DATE MM/DD/YYYY
DATE
X
Did you sign the form? Send the ENTIRE form and any attachments
to Fidelity Investments. You will receive a Revised Account Profile
confirming your distribution instructions.
Questions? Go to Fidelity.com/rmd or call 800-343-3548.
Regular mail
Fidelity Investments
Attn: Retirement Distributions
PO Box 770001
Cincinnati, OH 45277-0035
Overnight mail
Fidelity Investments
Attn: Retirement Distributions
100 Crosby Parkway KC1B
Covington, KY 41015
State Tax Withholding — IRA Withdrawals
Helpful to Know
• Each state sets its own withholding rates and require-
ments on taxable distributions. We apply these rates
unless you direct us not to (where permitted) or you
request a higher rate.
• Your account’s legal / residential address determines
which state’s tax rules apply.
• You are responsible for paying your federal, state, and
local income taxes and any penalties, including penal-
ties for insufficient withholding.
• Withholding taxes for Roth IRA distributions is optional.
• The state tax withholding rate, if indicated, must be
provided as a whole number from 1% to 100% for any
one-time withdrawals, or from 1% to 99% for any auto-
matic withdrawals.
Withholding Options
State of residence State tax withholding options
AK, FL, HI, NH, NV, SD,
TN, TX, WA, WY
• No state tax withholding is available (even if your state has income tax).
AR, IA, KS, MA, ME,
OK, VT
• If you choose federal withholding, you will also get state withholding at your state’s minimum withholding
rate or an amount greater as specified by you.
• If you do NOT choose federal withholding, state withholding is voluntary.
• If you have state withholding, you can request a higher rate than your state’s minimum but not a lower rate,
except on Roth IRA distributions.
CA, DE, NC, OR
• If you choose federal withholding, you will also get state withholding at your state’s minimum withholding
rate unless you request otherwise.
• If you do NOT choose federal withholding, state withholding is voluntary.
• If you have state withholding, you can request a higher rate than your state’s minimum but not a lower rate,
except on Roth IRA distributions.
CT, MI
• CT and MI generally require state income tax of at least your state’s minimum requirements regardless of
whether or not federal income tax is withheld.
• Tax withholding is not required if you meet certain state requirements governing pension and retirement
benefits. Please reference the CT or MI W-4P Form for additional information about calculating the amount
to withhold from your distribution.
• If you are subject to state tax withholding, you must elect state tax withholding of at least your state’s
minimum by completing the Tax Withholding section.
• Contact your tax advisor or investment representative for additional information about your state’s requirements.
DC
Only applicable if taking
a full distribution of entire
account balance.
• If you are taking distribution of your entire account balance and not directly rolling that amount over to
another eligible retirement account, DC requires that a minimum amount be withheld from the taxable
portion of the distribution, whether or not federal income tax is withheld. In that case, you must elect to
have the minimum DC income tax amount withheld by completing the Tax Withholding section.
• If your entire distribution amount has already been taxed (for instance only after-tax or nondeductible contributions
were made and you have no pre-tax earnings), you may be eligible to elect any of the withholding options.
• If you wish to take a distribution of both taxable and nontaxable amounts, you must complete a separate
distribution request form for each and complete the Tax Withholding section of the forms, as appropriate.
MS
• If you choose federal withholding, you will also get state withholding at your state’s minimum withholding
rate unless you request otherwise.
• If you do NOT choose federal withholding, state withholding will occur unless you request otherwise.
• If you have state withholding, you can request a higher rate than your state’s minimum but not a lower rate,
except on Roth IRA distributions.
OH
• State tax withholding is voluntary. If you choose state withholding, you can choose a higher rate than your
state’s minimum but not a lower rate, except on Roth IRA distributions.
SC
• SC requires state withholding if you have not provided a Tax ID or if you have been notified of a name/
Tax ID mismatch and have not resolved the issue. Otherwise, state tax withholding is voluntary and you can
choose the rate you want.
All other states
(and DC if not taking a
full distribution)
• State tax withholding is voluntary and you can choose the rate you want.
Important: State tax withholding rules can change, and the rules cited above may not reflect the current ruling of your state. Consult with
your tax advisor or state taxing authority to obtain the most up-to-date information pertaining to your state.
This tax information is for informational purposes only, and should not be considered legal or tax advice. Always consult a tax or legal
professional before making financial decisions.
We do not provide tax or legal advice and we will not be liable for any decisions you make based on this or other general tax information
we provide.
Fidelity Brokerage Services LLC, Member NYSE, SIPC; National Financial Services LLC, Member NYSE, SIPC 652041.6.0 (02/19)
Page 1 of 1
1.964543.105
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Automatic Investments Mrd Life Expectancy (Fidelity Investments)

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