Earnings Automatic Withdrawal Plan IRA
Use this form to establish, change, or delete an earnings automatic withdrawal plan for a Traditional, Roth, Rollover, SEP, SIMPLE,
Inherited, or Inherited Roth IRA. Use one form for each IRA. Do NOT use this form for Fidelity Retirement Plan accounts, workplace
savings accounts, annuities, or any Fidelity managed account. Not available to nonresident aliens due to special tax-withholding
requirements. 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 the relevant page.
Helpful to Know
By setting up an earnings automatic withdrawal plan,
you may elect to have any earnings (such as dividends
and capital gains) on certain mutual funds and eligible
securities distributed to you.
This plan is not intended to satisfy any required minimum
distributions (RMDs). It is your responsibility to ensure that
your withdrawals comply with IRS rules and deadlines for
RMDs, if applicable to you. You may want to consult a tax
advisor. Go to Fidelity.com/rmd to learn more about RMDs.
The earnings automatic withdrawal plan will only apply to
earnings from eligible securities where the reinvestment
instructions are set to cash, rather than reinvest.
• For mutual funds, note that:
Withdrawals could trigger redemption or transaction
fees (see the applicable fund prospectus).
If a fund is closed to new investors, you will not be
able to purchase new shares of the fund in the future
if you draw your fund balance down to zero.
If you are younger than 59½, early withdrawal penalties
may apply.
Certain corporate actions, such as a return of capital
or a tender offer, may result in your account receiving
unexpected earnings up to and including entire posi-
tions. The earnings automatic withdrawal plan does not
distinguish between these unusual corporate actions
and more routine earnings your account receives. If
your account receives corporate action payments, your
withdrawal for the subsequent period would include the
amounts received.
Note: For Mutual Fund Only accounts (accounts that
begin with a 2, followed by two letters):
The only scheduling option allowed in Section 2 is Daily.
The only distribution method allowed in Section 3 is
electronic funds transfer to an outside bank account in
your name only.
Federal tax withholding can either be set at no with-
holding or 10% in Section 4.
State tax withholding is applied only where required
(see the State Tax Withholding-IRA Withdrawals docu-
ment at the end of this form).
1. Account Owner
Name Fidelity Account Number
Social Security or Taxpayer ID Number
2. Distribution Request
Type of Request
ESTABLISH a new earnings automatic withdrawal plan
CHANGE an existing earnings automatic withdrawal plan
Fill out ONLY sections with changes.
DELETE an existing earnings automatic withdrawal plan
Skip to Section 5.
Reason for Distribution
Normal You are AT LEAST 59½ when your first distribution occurs.
Early You are younger than 59½ when your first distribution occurs and are not requesting substantially equal periodic
payments (SEPPs). IRS early distribution penalty may apply.
Death Taking distributions from an Inherited IRA or Inherited Roth IRA.
Earnings Automatic Withdrawal Plan Instructions Distributions will be made from the core account. If you want to change the reinvest-
ment instructions for each position individually, visit Fidelity.com/dividends.
Change existing dividends and capital gains instructions to pay ALL mutual funds’ dividends and capital gains
and ALL eligible securities’ dividends, interest, and capital gains in cash
Use existing dividends and capital gains instructions. Note: You cannot use reinvestment with an earnings
automatic withdrawal plan. Default if no choice indicated.
Check one.
Check one.
Check one.
Questions? Go to Fidelity.com/autowithd or call 800-343-3548.
1.940250.109 Page 1 of 4 028330701
Distribution Request continues on next page.
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Frequency of Earnings Automatic Withdrawal Plan Payments
Daily (D) Payments will be made every business day. You cannot request checks sent by mail with this option.
Weekly (W) Payments will be made every Friday.
Monthly (M) Payments will be made on the last Friday of each month.
Semimonthly (S) Payments will be made on the second and last Fridays of each month.
Quarterly (Q) Payments will be made on the last Friday of March, June, September, and December.
Weekly-PLUS (F) Payments will be made every Friday AND on the first business day following the 1st, 15th, and
22nd of each month.
Customized Schedule (X):
Every month
In the selected months of:
Jan Feb Mar Apr May Jun
Jul Aug Sep Oct Nov Dec
Day DD Day DD Day DD
3. Distribution Method
You must obtain a Medallion signature guarantee in Section 5 if establishing electronic funds transfer instructions for a bank account that is not
in your name, or if directing to a Fidelity account of which you are not the owner.
Directly deposited into a Fidelity nonretirement brokerage account. Deposits will be made to the core position.
(Available for brokerage accounts only.) Requires a Medallion signature guarantee if going to an account of
which you are not the owner.
Fidelity Nonretirement Account Number
Directly deposited into a Fidelity nonretirement Mutual Fund Only account. Account begins with a 2, followed by
two letters (example: 2AB-123456). (Available for brokerage accounts only.)
Fidelity Nonretirement Account Number Fidelity Fund Name or Symbol Mutual fund accounts ONLY.
Electronic funds transfer (EFT) to a bank or credit union account. To add EFT to an account, go to Fidelity.com/eft or
provide your bank information below.
If EFT cannot be established for any reason, a check will be sent to your address of record.
A. EFT to your bank account. You must be an owner on the Fidelity account and the bank account. Provide
your account information below. You must attach a voided check, deposit slip, or bank statement with
the account number and all owner names preprinted on it.
Checking Savings
B. 3rd Party EFT to someone else. (Available for brokerage accounts only.) The names on the bank account
and the Fidelity account are different. This option ONLY allows you to move money TO the outside account
and may not be used to make transfers for commercial purposes. Provide the account information below.
A Medallion signature guarantee is required in Section 5.
Owner(s) Name(s) Exactly as on Bank Account
Bank Routing/ABA Number Bank Name
Checking or Savings Account Number
Check mailed to the address of record. (Available for brokerage accounts only).
Default if no choice indicated or if
we are unable to process your choice.
Daily (D) must be
selected for Mutual
Fund Only accounts.
Check one.
If you check this box,
be sure to enter at
least one day and
select at least one
month option below.
Check one and
provide any required
information.
If you ONLY have
one set of EFT
instructions already
established for the
account referenced
in Section 1, check
the box and skip to
Section 4. Otherwise,
complete the
entire section.
Provide bank
information ONLY if
establishing new EFT
instructions OR if you
have multiple EFT
instructions available
for the account refer-
enced in Section 1.
Form continues on next page.
2. Distribution Request, continued
If you choose Daily in
Section 2, you cannot
select this option.
1.940250.109 Page 3 of 4 028330703
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.
1.940250.109 Page 4 of 4 028330704
Did you sign the form? Send the ENTIRE form and any attachments
to Fidelity Investments. You will receive a Revised Account Profile
confirming your distribution instructions.
Questions? Go to Fidelity.com/autowithd or call 800-343-3548.
Regular mail
Fidelity Investments
PO Box 770001
Cincinnati, OH 45277-0035
Overnight mail
Fidelity Investments
100 Crosby Parkway KC1K
Covington, KY 41015
On this form, “Fidelity” means Fidelity Brokerage Services LLC and its affiliates. Brokerage services are
provided by Fidelity Brokerage Services LLC, Member NYSE, SIPC. 610237.10.0 (10/19)
A Medallion signature guarantee is required:
• to establish EFT instructions for a bank account that is not in your name.
• if the withdrawals are going to a Fidelity account with no common owner.
If the form is completed at a Fidelity Investor Center, the Medallion signature guarantee is not required. You can get a Medallion sig-
nature guarantee from most banks, credit unions, and other financial institutions. A notary seal/stamp is NOT a Medallion signature
guarantee.
PRINT OWNER NAME
MEDALLION SIGNATURE GUARANTEE
OWNER SIGNATURE
SIGN
X
DATE MM/DD/YYYY
DATE
X
5. Signature and Date, continued
State Tax Withholding IRA Withdrawals
Helpful to Know
Each state sets its own withholding rates and require-
ments on taxable distributions. We apply these rates
unless you direct us not to (where permitted) or you
request a higher rate.
Your account’s legal / residential address determines
which state’s tax rules apply.
You are responsible for paying your federal, state, and
local income taxes and any penalties, including penal-
ties for insufficient withholding.
Withholding taxes for Roth IRA distributions is optional.
The state tax withholding rate, if indicated, must be
provided as a whole number from 1% to 100% for any
one-time withdrawals, or from 1% to 99% for any auto-
matic withdrawals.
Withholding Options
State of residence State tax withholding options
AK, FL, HI, NH, NV, SD,
TN, TX, WA, WY
• No state tax withholding is available (even if your state has income tax).
AR, IA, KS, MA, ME,
OK, VT
If you choose federal withholding, you will also get state withholding at your state’s minimum withholding
rate or an amount greater as specified by you.
If you do NOT choose federal withholding, state withholding is voluntary.
If you have state withholding, you can request a higher rate than your state’s minimum but not a lower rate,
except on Roth IRA distributions.
CA, DE, NC, OR
If you choose federal withholding, you will also get state withholding at your state’s minimum withholding
rate unless you request otherwise.
If you do NOT choose federal withholding, state withholding is voluntary.
If you have state withholding, you can request a higher rate than your state’s minimum but not a lower rate,
except on Roth IRA distributions.
CT, MI
CT and MI generally require state income tax of at least your state’s minimum requirements regardless of
whether or not federal income tax is withheld.
Tax withholding is not required if you meet certain state requirements governing pension and retirement
benefits. Please reference the CT or MI W-4P Form for additional information about calculating the amount
to withhold from your distribution.
If you are subject to state tax withholding, you must elect state tax withholding of at least your state’s
minimum by completing the Tax Withholding section.
Contact your tax advisor or investment representative for additional information about your state’s requirements.
DC
Only applicable if taking
a full distribution of entire
account balance.
If you are taking distribution of your entire account balance and not directly rolling that amount over to
another eligible retirement account, DC requires that a minimum amount be withheld from the taxable
portion of the distribution, whether or not federal income tax is withheld. In that case, you must elect to
have the minimum DC income tax amount withheld by completing the Tax Withholding section.
If your entire distribution amount has already been taxed (for instance only after-tax or nondeductible contributions
were made and you have no pre-tax earnings), you may be eligible to elect any of the withholding options.
If you wish to take a distribution of both taxable and nontaxable amounts, you must complete a separate
distribution request form for each and complete the Tax Withholding section of the forms, as appropriate.
MS
If you choose federal withholding, you will also get state withholding at your state’s minimum withholding
rate unless you request otherwise.
If you do NOT choose federal withholding, state withholding will occur unless you request otherwise.
If you have state withholding, you can request a higher rate than your state’s minimum but not a lower rate,
except on Roth IRA distributions.
OH
State tax withholding is voluntary. If you choose state withholding, you can choose a higher rate than your
state’s minimum but not a lower rate, except on Roth IRA distributions.
SC
SC requires state withholding if you have not provided a Tax ID or if you have been notified of a name/
Tax ID mismatch and have not resolved the issue. Otherwise, state tax withholding is voluntary and you can
choose the rate you want.
All other states
(and DC if not taking a
full distribution)
State tax withholding is voluntary and you can choose the rate you want.
Important: State tax withholding rules can change, and the rules cited above may not reflect the current ruling of your state. Consult with
your tax advisor or state taxing authority to obtain the most up-to-date information pertaining to your state.
This tax information is for informational purposes only, and should not be considered legal or tax advice. Always consult a tax or legal
professional before making financial decisions.
We do not provide tax or legal advice and we will not be liable for any decisions you make based on this or other general tax information
we provide.
Fidelity Brokerage Services LLC, Member NYSE, SIPC; National Financial Services LLC, Member NYSE, SIPC 652041.6.0 (02/19)
Page 1 of 1
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