Page 2 of 31.929800.105 007040502
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 or authorized individual 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 ben-
eficiaries, as applicable.
• Acknowledge that if you do not properly
name a beneficiary, or no beneficiary sur-
vives you, your beneficiary will be your
spouse or, if you are not married, your
estate in accordance with the rules of suc-
cession in the Plan Document.
• Acknowledge that, if you are married and
you designate anyone other than your
spouse as beneficiary, your designation
cannot be accepted without your spouse’s
notarized signature in Section 5.
• 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 remain-
der to the first named beneficiary.
• 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.
• Acknowledge that Fidelity has no respon-
sibility for the application of assets
distributed to beneficiaries.
PRINT OWNER/AUTHORIZED INDIVIDUAL NAME
OWNER/AUTHORIZED INDIVIDUAL SIGNATURE DATE MM/DD/YYYY
SIGN
X X
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
Form continues on next page.
