Page 2 of 21.925787.105 017860702
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%.
%
4. Signature and Date Account owner must sign and date.
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).
• 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 bene-
ficiary does not survive the account owner.
• 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.
• 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.
• Acknowledge that if you do not provide
percentages, the account will be divided
equally among primary or contingent
beneficiaries, as applicable.
• Acknowledge that if you do not properly
name a beneficiary, or no beneficiary
survives you, your beneficiary will be your
spouse or, if you are not married, your
estate, in accordance with the rules of
succession in the applicable Fidelity IRA or
HSA Custodial Agreement. (Not applicable
for annuities.)
• Agree that 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.
(For annuities, see product prospectus.)
• Agree that when your assets are
distributed to your beneficiaries, fractional
shares that cannot be distributed in
accordance with your instructions will
instead be given to the beneficiary
receiving the largest percentage of the
account’s assets or, if each beneficiary
is receiving an equal percentage, to the
last paid beneficiary. (Not applicable for
annuities.)
• Acknowledge that Fidelity has no
responsibility for the application of assets
distributed to beneficiaries.
Inherited IRAs
• Acknowledge that if you do not properly
name a beneficiary, or no beneficiary survives
you, the account will go to your estate
as provided in the applicable Fidelity IRA
Custodial Agreement.
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.”
3. Beneficiaries, continued
PRINT OWNER NAME
OWNER SIGNATURE 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. 574791.7.0 (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
