Questions? Go to Fidelity.com or call 800-343-3548.
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Certificate Release Request
Use this form to deposit a certificate into a Fidelity brokerage account when the name and registration on the certificate do not match
the name and registration on the Fidelity account. Use one form per certificate to be deposited. Type on screen or fill in using CAPITAL
letters and black ink. If you need more room for information or signatures, make a copy of this page.
1. Account Owner
Fidelity Account Number Name
Daytime Phone Extension
2. Certificate Information
Quantity of Shares Security Name Certificate Number Name(s) as Printed on Certificate
3. Signature(s) and Date(s) Current certificate holder(s) must sign and date.
By signing below, you:
• Authorize Fidelity to accept the shares of the security indicated in Section 2 and deposit said security into the account of the owner(s) named
above. The owner(s) may, for all purposes whatsoever, be treated as the sole owner(s) of said security and any of the proceeds thereof.
A Medallion signature guarantee is required.
If the form is completed at a Fidelity Investor Center with all signers present, 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 signature guarantee.
Important: The signature(s) must match exactly, without alteration, the name(s) as printed on your certificate.
PRINT CERTIFICATE OWNER NAME
MEDALLION SIGNATURE GUARANTEE
CERTIFICATE OWNER SIGNATURE
SIGN
X
TODAY’S DATE MM/DD/YYYY
DATE
X
PRINT CERTIFICATE OWNER NAME
MEDALLION SIGNATURE GUARANTEE
CERTIFICATE OWNER SIGNATURE
SIGN
X
TODAY’S DATE MM/DD/YYYY
DATE
X
Provide name(s) on
receiving account.
This phone number
may be used if we have
questions, but will not
be used to update your
account information.
Use a separate form
for each certificate
to be deposited.
On this form, “Fidelity” means Fidelity Brokerage Services LLC and its affiliates. Brokerage services are
provided by Fidelity Brokerage Services LLC, Member NYSE, SIPC. 157339.4.0 (08/20)
Did you print and sign the form? Send the ENTIRE form
to Fidelity Investments.
Questions? Go to Fidelity.com or call 800-343-3548.
Regular mail
Fidelity Investments
Attention: Banking Services
PO Box 770001
Cincinnati, OH 45277-0002
Overnight mail
Fidelity Investments
Attention: Banking Services
100 Crosby Parkway KC1N
Covington, KY 41015
