Fillable IRA Recharacterization Request (Fidelity Investments)

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IRA Recharacterization Request (Fidelity Investments)

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1.710137.112
Questions? Go to Fidelity.com or call 1-800-544-6666.
IRA Recharacterization Request
006930301
Use this form to recharacterize:
• any annual contributions you made to
a traditional IRA as annual Roth IRA
contributions;
• any annual contributions you made to a Roth
IRA as annual traditional IRA contributions;
• any conversion contributions you made to a
Roth IRA back to the original traditional IRA,
SEP-IRA, or SIMPLE-IRA (“deconverting”); or
• any qualied rollover contributions you made
to a Roth IRA or Inherited Roth IRA from a
workplace savings plan to a traditional IRA or
Inherited IRA.
Do NOT use this form for a conversion or reconversion. Type on screen or print out and ll in using CAPITAL letters and black ink.
Helpful to Know
• The IRS allows you to treat certain IRA contributions made
to one type of IRA as having been made to a different
type of IRA. This is known as “recharacterization.” You can
recharacterize all or part of the contribution amount. Any
net income attributable to the contribution also will be
recharacterized.
• All recharacterizations of Fidelity IRAs are processed in kind.
• All recharacterizations from any Inherited IRA must be
recharacterized into another Inherited IRA.
• Per IRS Notice 2000-39, calculation of the applicable
earnings is based on a pro rata portion of the earnings
accrued in the IRA during the period the IRA actually held
the contribution.
• Employer contributions to a SIMPLE-IRA or a SEP-IRA
cannot be recharacterized as contributions to any other IRA.
• The recharacterization request may not be modified or
revoked after it has been processed.
• Tax-reporting information: The IRS refers to the IRA from
which you are recharacterizing as the “First IRA,” and
the IRA to which you are recharacterizing as the “Second
IRA.” A recharacterized contribution will be treated for
federal income tax purposes as having been contributed
to the Second IRA on the same date and for the same
taxable year that the contribution was initially made to
the First IRA. The taxpayer is responsible for reporting all
recharacterization activity on IRS Form 8606, or as required
by the IRS. Please see instructions for 8606 for further
reporting information.
• Recharacterizations generally must be completed by the
federal income tax filing deadline (including extensions) for
the year for which the contribution was made to the first IRA.
• Reconversion Limit: You may not convert, recharacterize,
and then reconvert to a Roth IRA within the same tax year. If
you convert and subsequently recharacterize, you may not
reconvert back to a Roth IRA before the later of:
– The taxable year following the taxable year in which the
amount was first converted to a Roth IRA; OR
– The end of the 30-day period beginning on the day you
recharacterized from the Roth IRA to the non-Roth IRA.
• Complete a separate form for each transaction being
recharacterized.
• For information about reconversions and recharacterizations,
or to discuss your specific situation, please consult your tax
advisor. Additional information about limits and deadlines
may also be found on the IRS Web site, irs.gov.
• All open Good-Til-Cancelled (GTC) orders should be
cancelled prior to submitting this request. If a request
is received that requires transferring a position with an
open order, the order will be cancelled. It will be your
responsibility to replace the order on the receiving IRA
account, if applicable.
1. Account Owner
Name Social Security or Tax ID Number
Evening Phone Day Phone Extension
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1.710137.112
006930302
2. Recharacterization
Recharacterize all or part of an annual contribution, conversion, or qualied rollover contribution, as well as any
applicable earnings attributable to that contribution, in a trustee-to-trustee transfer from one Fidelity IRA to another
Fidelity IRA, as directed below:
Check one in
each column.
From Account
Account Number
Roth IRA
Traditional IRA
Inherited IRA
Inherited Roth IRA
Other
Specify
To Account
Account Number
Traditional IRA
Roth IRA
Inherited Roth IRA
Inherited IRA
Other
Specify
Contribution Information
Check one.
Annual contribution
Roth IRA conversion contribution
Qualied rollover contribution of non-Roth assets to a Roth IRA or Inherited Roth IRA from a workplace savings plan
Provide date of
contribution or
conversion. For multiple
contribution dates,
provide the initial date of
contribution.
Tax year of the contribution/conversion
Tax Year YYYY
Date of the contribution or conversion
Date MM DD YYYY
Amount of contribution or conversion
Amount
$
.
Partial Recharacterization
The entire annual contribution, conversion, or qualied rollover contribution indicated above will be recharacterized
unless you indicate a partial amount below.
Amount
$
.
Hierarchy of Assets to Be Recharacterized
We will recharacterize assets based on the following hierarchy unless a specic order is listed below:
1. Cash 2. Fidelity Funds 3. Non-Fidelity Funds 4. Stocks
1.
2.
3.
4.
Form continues on next page.
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1.710137.112 006930303
3. Signature Required
By signing below, you:
• Notify the Custodian of the Fidelity IRA,
Fidelity Management Trust Company, and
its agents, successors, or afliates that you
are electing to treat a contribution as having
been made to the Second IRA instead of the
First IRA as indicated on this form, for federal
tax purposes.
• Authorize and direct the Custodian to
recharacterize via a trustee-to-trustee transfer
the contribution and any applicable earnings
attributable to such contribution as you have
provided in Section 2.
• Accept full responsibility for complying with
the IRS requirements for recharacterizations
of IRA contributions.
• Hereby indemnify the Custodian for the
Fidelity IRA, its agents, afliates, successors,
and employees from any and all liability in the
event you fail to meet these requirements.
Print Owner Name
Owner Signature Date MM - DD - YYYY
SIGN
Did you sign the form? Send the ENTIRE form and any
attachments to Fidelity Investments. You will receive a
Revised Account Prole.
Questions? Go to Fidelity.com or call 1-800-544-6666.
Use postage-paid envelope, drop off at a Fidelity Investor Center, OR deliver to:
Regular mail
Attn: Retirement Distributions
Fidelity Investments
P.O. Box 770001
Cincinnati, OH 45277-0035
Overnight mail
Attn: Retirement Distributions
Fidelity Investments
100 Crosby Parkway KC1B
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. 432420.4.0 (07/13)
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IRA Recharacterization Request (Fidelity Investments)

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Completed 20 March 2022

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