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7. Tax Withholding
Distributions 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 withholding, federal income tax will be withheld at the rate of 10% from your total IRA distribution amount, unless
you indicate a higher percentage below (federal and state tax withholding combined cannot total more than 99%). If you made nondeduct-
ible 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 sufficient.
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.
%
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 make the withdrawals indicated in this
form from the IRA account indicated in
Section 1.
• Acknowledge that non-Roth IRA distribu-
tions will generally be taxed as ordinary
income, and may be subject to a 10% early
withdrawal penalty if taken before age 59½.
• Acknowledge that distributions 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 SEPP:
• Accept full responsibility for SEPP plan set
up and withdrawing from your Traditional,
Rollover, SEP, or SIMPLE IRA, in accordance
with applicable IRS rules.
• Acknowledge that Fidelity will report all
SEPP distributions to the IRS as “early dis-
tribution — no known exception applies.”
• Acknowledge that any changes to or
transactions in addition to those made
through your SEPP automatic withdrawal
plan could disqualify your SEPP plan and
may be subject to early withdrawal penalty
if you are under age 59½ or made within
five years.
Customers requesting EFT:
• Authorize and request Fidelity to make EFT
distributions from the Fidelity IRA listed in
this form by initiating debit entries to such
Fidelity IRA.
• 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
party’s account identified in Section 6 is
owned by a natural person, (ii) that person
has authorized his/her account to be cred-
ited 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 withholding.
Otherwise, penalties may apply. The penalty
for reporting false information is a fine of
not more than $5,000, imprisonment for not
more than five years, or both.
• Confirm that your state tax withholding
election is true, complete, and correct.
Check one in each
column. IRA owner’s
legal/residential
address determines
which state’s tax
rules apply.
1.931221.109
Signature and Date continues on next page.
