Fill - Free fillable Beneficiaries Transfer On Death /BOSTON/xinet/BosWork/Jobs/25543/PIECE68/25543 68 FRM TOD BENE Fill (Fidelity Investments) PDF form

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Questions? Go to Fidelity.com/beneficiary or call 800-343-3548.

Beneficiaries — Nonretirement Transfer on Death

Use this form to establish or update the beneficiaries on a Transfer on Death (TOD) registration on your nonretirement Fidelity Account

or Fidelity Funds Account registered as Individual, Joint Tenants with Rights of Survivorship, or Tenants by the Entirety. Do NOT use for

retirement accounts or 529 College Savings Plans. Type on screen or print out and fill in using CAPITAL letters and black ink. If you need

more room for information or signatures, make a copy of the relevant page.

Helpful to Know

• This form preempts any terms in your will concerning

the accounts in question. You may want to review this

document with a tax, financial, or legal adviser.

• Transfer on Death registrations are not available

in Louisiana. Please consider consulting an attorney,

tax professional, or estate planner familiar with your

particular situation.

• ALL account owners must sign this form.

• Please read and review the Designated Beneficiary

Agreement attached at the end of this form.

• Tenants-in-common cannot have TOD registrations.

• This form cancels any existing beneficiary information.

Be sure this form includes ALL beneficiaries you want on

the account(s).

• You can change beneficiaries any time at Fidelity.com/

beneficiary. To add or change beneficiaries on other

types of accounts, go to Fidelity.com/forms.

1. Account Owner

Name

Additional Name(s)

Daytime Phone Extension

2. Accounts Included

For new accounts, attach a copy of account opening form instead of listing account numbers below.

Fidelity Account Number Fidelity Account Number Fidelity Account Number

This phone number will

be used if we have

questions, but will not

be used to update your

account information.

List all accounts you

want this form to

apply to. To indicate

different beneficiaries

for different accounts,

use copies of this form.

1.925788.104 002070601

Form continues on next page.

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Page 2 of 51.925788.104 002070602

3. Beneficiaries

Primary Beneﬁciaries

Spouse

Non-Spouse

Name If naming spouse as a beneficiary, do so here.

Trust

Other Entity

Social Security or Taxpayer ID Number Date of Birth/Trust MM DD YYYY Share Percentage

Per stirpes

Non-Spouse

Trust

Other Entity

Name

Social Security or Taxpayer ID Number Date of Birth/Trust MM DD YYYY Share Percentage

Per stirpes

Non-Spouse

Trust

Other Entity

Name

Social Security or Taxpayer ID Number Date of Birth/Trust MM DD YYYY Share Percentage

Per stirpes

Non-Spouse

Trust

Other Entity

Name

Social Security or Taxpayer ID Number Date of Birth/Trust MM DD YYYY Share Percentage

Per stirpes

Total must add up to 100%.

Contingent Beneﬁciaries

Spouse

Non-Spouse

Name If naming spouse as a beneficiary, do so here.

Trust

Other Entity

Social Security or Taxpayer ID Number Date of Birth/Trust MM DD YYYY Share Percentage

Per stirpes

Non-Spouse

Trust

Other Entity

Name

Social Security or Taxpayer ID Number Date of Birth/Trust MM DD YYYY Share Percentage

Per stirpes

Non-Spouse

Trust

Other Entity

Name

Social Security or Taxpayer ID Number Date of Birth/Trust

MM DD YYYY Share Percentage

Per stirpes

Non-Spouse

Trust

Other Entity

Name

Social Security or Taxpayer ID Number Date of Birth/Trust MM DD YYYY Share Percentage

Per stirpes

Total must add up to 100%.

For each beneficiary

you list, check a

beneficiary type and

provide all information,

including the full first

and last name as

evidenced by a govern-

ment-issued, unexpired

document (e.g., driver’s

license, passport, per-

manent resident card).

If you outlive a

beneficiary and you

want that beneficiary’s

share to go to his or her

descendants, check

“Per stirpes.”

Contingent beneficiaries

receive assets only if no

primary beneficiary

survives you.

Do NOT list any primary

beneficiaries here.

If you outlive a

beneficiary and you

want that beneficiary’s

share to go to his or her

descendants, check

“Per stirpes.”

Form continues on next page.

Page 3 of 51.925788.104 002070603

4. Signature(s) and Date(s) ALL account owners must sign and date.

In this form, “Fidelity,” “us,” and “we” refer to Fidelity Brokerage Services LLC, Fidelity Distributors Company LLC, and National Financial

Services LLC and their affiliates, and their employees, agents, representatives, shareholders, successors, and assigns as the context may

require; and “You,” “you,” and “your” refer to all account holders, including individual, joint, trustees, and/or custodians.

By signing below, you:

• Affirm that the beneficiary information

provided on this form replaces any prior

beneficiary information that may be on

record for the indicated account(s).

• Affirm that you have received, read,

understood, and agree to be bound by

the terms and conditions in the attached

Designated Beneficiary Agreement and

this form, as is currently in effect and

as may be amended in the future. The

Designated Beneficiary Agreement and

this form shall inure to the benefit of

Fidelity’s successors and assigns, whether

by merger, consolidation, or otherwise.

• Acknowledge that, if you check “per

stirpes,” that any share otherwise payable

to a beneficiary shall instead be paid to

that beneficiary’s surviving descendants by

right of representation if the original benefi-

ciary does not survive the account owner(s).

• Acknowledge that “per stirpes” creates a

category of beneficiaries (for example, the

children of a beneficiary), and therefore

may end up including individuals not yet

born or adopted.

• Acknowledge that listing beneficiaries

by name does NOT create a category of

beneficiaries, and that if you later want to

include other beneficiaries, you will need

to submit a new beneficiary form.

• Acknowledge that if you do not provide per-

centages, the account will be divided equally

among primary beneficiaries or among con-

tingent beneficiaries, as applicable.

• Agree that Fidelity has no obligation

to locate or notify any beneficiary or to

independently verify any information

submitted by any person claiming an

interest in your account.

• Agree that when your assets are distrib-

uted to your beneficiaries, fractional shares

that cannot be distributed in accordance

with your instructions will instead be given

to the beneficiary receiving the largest per-

centage of the account’s assets or, if each

beneficiary is receiving an equal percent-

age, to the last paid beneficiary.

PRINT OWNER NAME

OWNER SIGNATURE TODAY’S DATE MM/DD/YYYY

SIGN

X X

PRINT ADDITIONAL OWNER NAME

ADDITIONAL OWNER SIGNATURE TODAY’S DATE MM/DD/YYYY

SIGN

X X

On this form, “Fidelity” means Fidelity Brokerage Services LLC and its affiliates. Brokerage services are

provided by Fidelity Brokerage Services LLC, Member NYSE, SIPC. 574792.4.0 (05/20)

Did you sign the form? Send the ENTIRE form to Fidelity. You will receive

a “Revised Account Profile” confirming your updates.

Questions? Go to Fidelity.com/beneficiary or call 800-343-3548.

Regular mail

Fidelity Investments

PO Box 770001

Cincinnati, OH 45277-0002

Overnight mail

Fidelity Investments

100 Crosby Parkway KC1K

Covington, KY 41015

0020706041.925788.104 Page 4 of 5

Beneficiaries — Nonretirement Transfer on Death

Designated Beneficiary Agreement Keep this for your records.

This Agreement creates a transfer on death (“TOD”) registration

for an account upon the death of an individual account holder

or of the last surviving account holder in eligible joint accounts

(“Date of Death”) of a nonretirement Fidelity Account or Fidelity

Funds Account (the “Account”). The disposition of assets held in

the Account is controlled by the terms of this agreement and the

Beneficiaries—Nonretirement Transfer on Death Form (the “Form”),

which is incorporated into this agreement by reference (collectively,

the “Agreement”). “Fidelity” as used herein refers collectively to

Fidelity Brokerage Services LLC, Fidelity Distributors Company LLC,

and National Financial Services LLC. The assets in the Account

subject to the Agreement (“eligible assets”) will be transferred to

beneficiaries designated in the Form. The term “account holder”

means an individual account owner and, in the case of an eligible

joint Account, means each account holder or the last surviving joint

owner as indicated by the context. References to the estate of the

account holder shall mean the estate of the last surviving account

holder. The beneficiary designation and disposition of assets made

under the Agreement will take precedence over any disposition

contained in other documents such as a will, trust, premarital or

other legal document, even if specific reference is made therein to

the Agreement or to one or more specific Accounts, or any oral or

written agreement as to the disposition of eligible assets, except

by court order received by Fidelity in time for it to act before it

makes transfers under the Agreement. Fidelity does not give legal

or tax advice in connection with the Agreement, and account hold-

ers are advised to consult with their legal, tax, financial and estate

planning professionals before making any beneficiary designation.

Fidelity has not advised, nor is it obliged to advise, account owners

as to the suitability of the Agreement for the account holder. This

Agreement does not constitute a trust, and Fidelity has no fiduciary

duty as a trustee under the Agreement to the account holder, any

beneficiary under the Agreement or any other third party.

The Agreement supplements and does not replace any of the

terms and conditions of the applicable Customer Agreement for

the Account, a fund prospectus or any other terms and conditions

between the account holder and Fidelity that apply to the Account.

If the Agreement should conflict with any such other terms and

conditions, the Agreement will control. The Agreement may be

amended from time to time by Fidelity by written notice to the

account holder and the terms of the Agreement in effect at the

death of the last surviving account holder will control the disposition

of eligible assets under the Agreement.

While any account holder is living, Fidelity reserves the right to ter-

minate the Account, to revoke the Agreement and to require that

assets held in an Account be transferred to an account to which the

Agreement does not apply.

Fidelity may refuse to accept any beneficiary designation made by

an account holder under the Agreement. Certain assets, including,

but not limited to, any insurance, endowment policy or annuity con-

tract, are ineligible for the Agreement (“ineligible assets”). Limited

partnership interests may be ineligible assets due to a partnership

agreement or transfer agent conditions. Fidelity disclaims all liability

for a failure to transfer any ineligible assets. If an Account should

hold ineligible assets at the Date of Death and the disposition of

these ineligible assets is not governed by an agreement or contract

specifically related to the ineligible assets, the ineligible assets will

be paid to the estate of the account holder.

A. Eligibility for the Agreement In order to be eligible for TOD

registration, an account must be a registered individual or eligible joint

Account (i.e., joint tenants with rights of survivorship, or tenants by the

entirety). Accounts with any other registration (“ineligible accounts”)

must be changed to an eligible Account to qualify for TOD registra-

tion. If an eligible Account is changed from an individual registration

to a joint registration or if an eligible Account is changed to an ineli-

gible account, the Agreement is terminated as of the date of such

re-registration and upon the Date of Death all assets in the Account

will be paid to the estate of the account holder.

B. Effective Date The effective date of the Agreement is when

the Form is signed by the account holder (“Effective Date”). The

Form must be received and accepted by Fidelity no later than thirty

(30) days after the Date of Death of the account holder. Fidelity may

re-register the Account and dispose of the assets at any time after it

has accepted the Form. Any Form that is not signed and dated by

the account holder will not be accepted.

C. Determination of Beneficiaries The term “per stirpes”

means that if any primary or contingent beneficiary dies before the

account holder but has surviving descendants, that beneficiary’s

share is paid to such surviving descendants by right of representa-

tion. If the account holder designates beneficiaries as per stirpes,

persons within that group of descendants living on the Effective

Date and on the Date of Death are included. Such group of descen-

dants may end up including individuals not yet born, adopted, or

otherwise a member of the group on the Effective Date. Otherwise,

only named beneficiaries will share in the Account assets, and

others who may be in the same group of descendants as named

individuals (e.g., other children or grandchildren) but who are not

named will not share in the Account assets whether they were born,

adopted or otherwise became a member of the group before or

after the Effective Date. Only beneficiaries living on the Date of

Death are eligible to receive Account assets. Fidelity is authorized

to rely on any representation of facts made by the account holder,

the personal representative of the estate of the account holder, any

beneficiary, or any other person or source deemed appropriate by

Fidelity in determining the identity of unnamed beneficiaries.

If a non-person (e.g., a trust or corporation) is named as a benefi-

ciary and it is not in effect or in existence on the Date of Death,

it will be deemed not to have survived the account holder. To

establish facts related to the Account, including the time and dates

of death, Fidelity may rely on public records, including a death

certificate and other information furnished to it by a beneficiary, the

personal representative of the estate of the account holder, or any

other source deemed appropriate by Fidelity.

If your beneficiary allocation totals at least 99%, but less than 100%

(e.g., 3 named beneficiaries are each assigned a 33% interest in the

account), Fidelity will assign the unallocated remainder to the first

named beneficiary.

If the account holder has not designated the beneficiaries for any

portion of the eligible assets for any reason, including but not

limited to the percentages of eligible assets total less than 100%,

or because one or more beneficiaries is deceased on the Date of

Death, such eligible assets shall be distributed to the primary ben-

eficiaries who survive the account holder in the same proportion that

their original shares bear to each other or, if no primary beneficiary is

then living, such eligible assets shall be distributed to the contingent

beneficiaries who survived the account holder in the same propor-

tion that their original shares bear to each other. The term “primary

beneficiary” shall mean: (1) a named primary beneficiary; or (2)

descendants of a deceased named primary beneficiary for whom the

account holder has selected per stirpes. Distributions made because

the account holder has selected per stirpes shall be paid as follows:

Questions? Go to Fidelity.com/beneficiary or call 800-343-3548.

0020706051.925788.104 Page 5 of 5

the eligible assets are divided into as many equal shares as there

are living children of the account holder or designated named ben-

eficiary and deceased children of the account holder or designated

named beneficiary who have descendants living. Each living child

is allocated one share. The share of each deceased child with living

descendants is allocated one share, which is divided equally among

such living descendants. This subdivision is repeated at each suc-

ceeding generation until the property is fully allocated among living

descendants. For example, if per stirpes has been selected and if

the account holder at the Date of Death has two living children and

one deceased child who has three living children (i.e., grandchildren

of the account holder), each living child of the account holder would

receive one-third of the eligible assets and each of the three children

of the deceased child would receive one-ninth of the eligible assets.

Division among the descendants of a named beneficiary would occur

in the same manner as to the share of the named beneficiary. The

term “descendants” shall include both natural and legally adopted

descendants living at the Date of Death.

If no primary or contingent beneficiary is living on the Date of Death,

the Account assets will be paid to the estate of the account holder.

D. Changes to Beneficiary Designations The account holder

may at any time change the named beneficiaries or revoke the

designations made under the Agreement. A subsequent Form will

revoke a prior designation of beneficiaries when the Form becomes

effective (i.e., signed, delivered to, and accepted by Fidelity, and

submitted in a form and manner acceptable to Fidelity).

Except as provided with respect to descendants of the account

holder who become beneficiaries because the account holder has

selected per stirpes, changes in the relationship between the account

holder and any other beneficiary, including, but not limited to, sub-

sequent marriage, dissolution of marriage, remarriage or adoption,

will not automatically add or revoke designations of beneficiaries.

For example, if a former spouse was a designated beneficiary prior

to dissolution of the marriage, the former spouse would remain a

beneficiary after the dissolution unless his or her designation as

a beneficiary was expressly revoked by execution of a new Form

signed by the account holder and received and accepted by Fidelity.

E. Payment on Death Until the Date of Death, the account

holder retains complete control over the assets in the Account, the

beneficiaries have no interest in the Account, and there will be no

transfers made pursuant to the Agreement. All eligible assets in

the Account must be held at Fidelity at the Date of Death in order

to be distributed to beneficiaries. Fidelity may liquidate assets to

pay and transfers will be reduced by any financial obligation of the

account holder to Fidelity, including, but not limited to, any margin

debt balance or if the Account is subject to any taxes. Transfers shall

be increased by any amounts payable to the Account but not paid

or credited before the Date of Death. Unless otherwise instructed,

all income paid to the Account after the assets have been initially

apportioned (i.e., residual income) will be systematically allocated

to the beneficiary receiving the largest share proportion of the

account assets. If the account is transferred evenly, the income

and/or fractional shares will be systematically allocated to the last

beneficiary paid. Amounts paid or credited after Date of Death but

before Fidelity has had reasonable time to act following the account

holder’s death will be paid to the estate of the account owner.

Each designated beneficiary must notify Fidelity of the death of

the account holder and provide in a timely manner: (1) either the

account number of an existing Fidelity account of which the benefi-

ciary is an owner or a completed and signed Change of Registration

Form or new account application, as applicable (if not previously

provided); (2) a copy of the death certificate; (3) a tax waiver if

required by state law; and (4) such additional necessary and/or

appropriate information or documents as Fidelity may require.

Fidelity may require a certification of the identity of the beneficiaries

from the personal representative of the estate of the account holder

or any other appropriate person.

Fidelity will require each beneficiary to open an account at Fidelity

or to identify an appropriate existing Fidelity account in order to

facilitate transfer of the Account’s eligible assets and to execute an

indemnification in the amount of the Account’s assets.

Transfer of assets in the Account will begin as soon as practicable

after the Date of Death.

Fidelity has no obligation to: (1) locate any beneficiary, the spouse

or legal heirs of any account holder or the personal representative

of the estate of any account holder; (2) notify any person of any pro-

posed or completed transfer of eligible assets; or (3) independently

verify any information submitted by any person claiming an interest

in the Account.

In the event of reasonable doubt as to disposition of Account

assets, Fidelity may resolve such doubt by judicial determination,

which shall be binding on all parties claiming any interest in the

Account. All legal and other applicable expenses shall be paid from

the assets of the Account.

F. Payments to Minors and Other Beneficiaries Under

Incapacity If a beneficiary is a minor or otherwise under a legal

disability, Fidelity may, in its absolute discretion, make all, or any

part of the distribution for such beneficiary to: (1) a parent of such

beneficiary; (2) the guardian, conservator, or other legal repre-

sentative, wherever appointed, of such beneficiary; (3) an existing

custodial account established for such beneficiary under a Uniform

Transfers to Minors Act or similar act; (4) any person having control

or custody of such beneficiary; or (5) to such beneficiary directly. If

there is no person having control or custody or no existing custodial

account of such beneficiary, nor a court-appointed custodian or

guardian, Fidelity may request such appointment for the distribution

of any eligible assets payable to such beneficiary.

G. Indemnity The account holder, the estate and successors-

in-interest of the account holder, including all beneficiaries, shall

fully indemnify and hold harmless Fidelity, its agents, affiliates,

control persons, successors and assigns and their directors, officers,

employees and agents from and against all claims, actions, costs

and liabilities, including attorneys’ fees, by or to any person or

entity, including any beneficiary, any creditor of the account holder,

the estate of the account holder and the account holder’s heirs, suc-

cessors and assigns, arising out of or relating to:

• Any designation of a beneficiary made under the Agreement that

conflicts with any beneficiary designation made in the account

holder’s will, trust, premarital agreement, other oral or written

agreement or any other legal document.

• Any written change of beneficiaries by the account holder that has

not been received by and accepted by Fidelity.

• Any other action taken by Fidelity in opening and maintaining the

Account under the Agreement, registering assets in the name of

the Account and completing transfers from the Account upon the

Date of Death, including, but not limited to, Fidelity’s reliance on

individuals or sources named in this Agreement.

H. Governing Law. This Agreement and its enforcement are gov-

erned by the laws of the Commonwealth of Massachusetts, except

with respect to its conflicts-of-law provisions. The Agreement shall

inure to the benefit of Fidelity’s successors and assigns, whether by

merger, consolidation or otherwise, and shall be binding upon the

heirs, personal representatives, successors and assigns of the account

holder and the beneficiaries designated by the account holder.

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