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4. Tax Withholding
Automatic withdrawals 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 withhold-
ing, 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 nondeductible 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 with-
drawals 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. *For Mutual Fund Only Accounts,
you can only elect no withholding or 10%.
%
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.
†
For Mutual Fund Only
Accounts, only the minimum state tax
withholding applies where required.
%
5. Signature and Date
By signing below, you:
• Authorize and request the custodian for
the Fidelity IRA, Fidelity Management Trust
Company and its agents, affiliates, employ-
ees, or successor custodians (Fidelity) to
withdraw your earnings for the IRA account
indicated in Section 1 of this form.
• Acknowledge that non-Roth IRA withdraw-
als will be taxed as ordinary income, and
may be subject to a 10% early withdrawal
penalty if taken before age 59½.
• Acknowledge that withdrawals 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.
• Acknowledge that withdrawals made from
any earnings plans are not calculated or
intended to satisfy any RMD requirement
and that you accept full responsibility for
withdrawing any RMD from your Traditional,
Rollover, SEP, SIMPLE, Inherited IRA, or
Inherited Roth IRA, in accordance with appli-
cable IRS rules beginning at age 70½ or as
required. RMDs for inherited accounts can be
required to begin as early as the year after
the death of the original owner.
• Indemnify Fidelity from any liability in
the event that you fail to meet the IRS
requirements.
•
Certify under penalties of perjury that you are
a U.S. citizen or other U.S. person (including a
resident alien individual) and that the tax iden-
tification number shown on this form is your
correct tax identification number.
• Understand that Fidelity may terminate this
feature from your account at any time.
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 financial
institution specified in your existing instruc-
tions (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 rea-
sonable procedures to prevent unauthorized
transactions. You agree that this authoriza-
tion may only be revoked by written notice
to us in such time and manner as to afford us
and the Bank a reasonable opportunity to act
upon it.
• Warrant and represent that (i) the third
party’s account identified in Section 3 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 on a
periodic basis without notice to you.
• Understand that Fidelity may terminate the
EFT instructions from your account 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 elec-
tion is true, complete, and correct.
Check one in each
column. IRA owner’s
legal/residential
address determines
which state’s tax
rules apply.
Signature and Date continues on next page.
