1.852488.108 Page 3 of 3 019250603
On this form, “Fidelity” means Fidelity Brokerage Services LLC and its affiliates. Brokerage services are
provided by Fidelity Brokerage Services LLC, Member NYSE, SIPC. 467758.10.0 (08/19)
Did you sign the form? Send the ENTIRE form
to Fidelity Investments.
Questions? Go to Fidelity.com or
call 800-544-3716.
Regular mail
Attn: Retirement Distributions
Fidelity Investments
PO Box 770001
Cincinnati, OH 45277-0035
Overnight mail
Attn: Retirement Distributions
Fidelity Investments
100 Crosby Parkway KC1B
Covington, KY 41015
4. Signature and Date Account owner must sign and date.
By signing below, you:
•
Authorize and request the custodian of the
Fidelity HSA
®
, Fidelity Personal Trust Company
and its agents, affiliates, employees, or
successor custodians (“Fidelity”), to execute
the instructions you have provided above.
• Understand that withdrawals from your HSA,
including earnings, will be tax free (for fed-
eral tax purposes) if used to pay for qualified
medical expenses for yourself, your spouse,
and your dependents. Withdrawals used
to pay for expenses other than qualified
medical expenses are considered taxable
income and will be subject to an additional
20% penalty. The 20% penalty will not apply
to withdrawals made after your death, you
become disabled, or once you reach age 65.
• Understand that you are responsible for
determining whether or not a particular
medical expense is a qualified expense
and that you must keep all receipts and
records for tax purposes. Qualified medi-
cal expenses are defined by the Internal
Revenue Code and generally cover most
medical care and services, dental and vision
care, prescription drugs (including pre-
scribed over-the-counter drugs) and insulin
that are not covered by insurance or other-
wise. For more details on what constitutes
a qualified medical expense, please refer to
IRS publications 969 and 502 or contact a
tax professional.
• Indemnify Fidelity from any liability
in the event that you fail to meet any
IRS requirement.
• Confirm, if you are not a U.S. person, that
you have attached, or have on file with
Fidelity, IRS Form W-8BEN that includes your
U.S. or foreign tax identification number.
Customers requesting EFTs
•
Authorize and request Fidelity to make EFT
distributions by initiating debit entries from the
Fidelity HSA account indicated on this form.
• Authorize and request the bank named in
Section 3 to accept debit entries initiated
by Fidelity in such account and to credit
the bank account in accordance with these
entries without responsibility for the appro-
priateness or for the existence of any further
authorization.
A Medallion signature guarantee is required:
• to send a check to an alternate address or payee.
• to request a bank wire.
• if the address on the account has been changed within the past 10 days.
• if the withdrawal is going to a Fidelity account with no common owner.
• if the transaction is greater than $100,000.
If the form is completed at a Fidelity Investor Center, 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 Medallion signature guarantee.
PRINT OWNER NAME
MEDALLION SIGNATURE GUARANTEE
OWNER SIGNATURE
SIGN
X
DATE MM/DD/YYYY
DATE
X
