Fillable IRA Return Excess Contribution Request (Fidelity Investments)

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IRA Return Excess Contribution Request (Fidelity Investments)

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Use this form if you have made an excess contribution to your Traditional IRA or Rollover IRA, Roth IRA, or an excess direct
rollover to an Inherited IRA or Inherited Roth IRA. You are encouraged to consult a tax advisor concerning the correction of excess
IRA contributions and your personal situation before completing this form.
Do not use this form to recharacterize contributions between a Traditional IRA and a Roth IRA. The Fidelity IRA Request for Recharacterization
Form should be used. Please consult your tax advisor regarding excess contributions to a SIMPLE-IRA, SEP-IRA, Fidelity Retirement Plan
(Keogh), or Fidelity Self-Employed 401(k).
If you are correcting an excess contribution before your tax-filing deadline, the Internal Revenue Service (IRS) requires a calculation to determine
the earnings or loss on the excess IRA contribution. The earnings or loss amount is factored into the amount of your return of excess distribution.
Fidelity will automatically calculate the amount of earnings or loss based on IRS Notice 2000-39 and IRS Final Regulation 1.408-11. If you wish to
calculate the earnings or loss instead of Fidelity, please include a signed letter of instruction with this form.
If you timely filed your tax return without withdrawing the excess IRA contribution, the IRS allows an extra six months to correct your excess
contribution using Method 1 (see Section 3). In most cases, this extends the deadline for Method 1 to October 15 of the tax year in which the
excess contribution was made.
If you are correcting an excess contribution after your tax-filing deadline and you wish to carry forward the full amount of the excess con-
tribution to a subsequent tax year(s), see Section 3, Method 3, for more information. Do not complete this form and return it to Fidelity.
Please consult your tax advisor.
If you have any questions, contact a Fidelity Retirement Representative at 1-800-544-4774, 8 a.m. to 9 p.m. Eastern time. Please use a pen and
print clearly. Return the completed form to:
Regular Mail: Fidelity Investments Overnight Mail: Fidelity Investments
Attn: Distributions KC1D Retirement Distributions KC1D
PO Box 770001 100 Crosby Parkway
Cincinnati, OH 45277-0035 Covington, KY 41015-4325
Fidelity IRA Return of Excess Contribution Request
006940301
Page 1 of 4
1.738841.112
1
CUSTOMER INFORMATION
Name: Contact phone number
(First, MI, Last)
Social Security number Date of birth
2
EXCESS CONTRIBUTION DESCRIPTION
Indicate the Fidelity IRA that includes the excess IRA contribution, when the excess contribution occurred, and indicate the specific fund(s)
from which to remove any excess plus net earnings, if applicable.
Account number:
–
Tax Year for which the excess contribution was made
Date of the deposit
If you have multiple excess contributions, provide the date of the first excess contribution.
Amount of excess contribution
$ , .
Do not include any earnings or loss on the excess contribution.
Type of Fidelity IRA: (check one)
Check here if this is a Fidelity Brokerage IRA.
The excess contribution plus any earnings or loss, if applicable, will be removed from the core account. If there is insufficient cash in the
core account, you will need to place a liquidating trade before the excess contribution can be removed. Trade online at Fidelity.com or
call a representative at 1-800-544-8666. Allow at least three business days for trade settlement.
Check here if this is a Fidelity Funds IRA.
The excess contribution plus any earnings or loss, if applicable, will be removed from the specific mutual fund(s) you indicate below. Please
indicate the distribution percentage from each fund. The total of percentages should be 100%.
Fund Name Percentage Fund Name Percentage
1.
% 3. %
2. % 4. %
100%
Print
Reset
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3
METHOD OF CORRECTION
Choose one method to correct your excess IRA contribution. Your choice will depend on when you made the original contribution,
your tax-filing deadline (plus extensions), and today’s date. Please review all options before selecting which one is right for you. If the
correction applies to an Inherited IRA or Inherited Roth IRA, only Method 1, option C, should be used.
Method 1: Correction Before Tax-Filing Deadline (plus extensions)
I am correcting this excess contribution before the later of my tax-filing deadline (including any extensions) of the year in which the
excess contribution was made, or within six months of my tax-filing deadline if I timely file my tax return.
I understand that this correction is a taxable event and that I will receive a 1099-R form for the full amount of the excess plus any applicable earn-
ings. The earnings should be included as income in the year the contribution was made, and may be subject to a 10% penalty if I am under age 59
1
⁄2.
Choose A, B, or C for how you would like to have the excess amount disbursed. If no option is selected, we will default to option C
for this method.
A. Redeposit the full amount of the excess plus earnings back into this IRA as a tax year IRA contribution.
B. Redeposit the amount of $ , back into this IRA as a tax year IRA contribution
and return the balance to me as indicated in Section 4.
C. Distribute the full amount of the excess contribution to me as indicated in Section 4.
Method 2: Correction After Tax-Filing Deadline
This method does not apply to withdrawing nondeductible contributions (including Roth IRA contributions).
I am correcting this excess after my tax-filing deadline (including extensions) of the year in which the excess contribution was made. I understand
that this correction is a taxable event and that I will receive a 1099-R form for the full amount of the excess being distributed. I also understand that
I will owe a 6% penalty on the amount of the excess contribution for each year it has remained in my IRA and was not corrected, and that I may be
subject to a 10% penalty on the entire amount returned to me if I am under age 59
1
⁄2.
Indicate in Section 4 — “Method of Payment” — how you would like to have the excess amount disbursed.
Method 3: Carryover of Excess Amount After Tax-Filing Deadline
***Do not return this form to Fidelity if choosing this method.*** You must file IRS form 5329.
I am correcting this excess after my tax-filing deadline (including extensions) of the year in which the excess contribution was made, and am apply-
ing the full amount of the excess as contributions to subsequent tax year(s) until the full amount of the excess contribution is depleted. Earnings
attributable to the excess contribution do not need to be distributed if I choose this method. There will be a 6% IRS penalty due on the amount of
the excess contribution for each year it has remained in my IRA until it is properly applied as a subsequent year contribution.
Follow these steps for each subsequent year and retain this document for your files:
1. Indicate subsequent tax year(s) for which you are assigning an IRA contribution
.
2. Indicate the amount of the contribution you are making from the original excess amount $ , .
For tax year 2009–2010, the maximum IRA contribution is $5,000 ($6,000 for individuals age 50 and over).
4
METHOD OF PAYMENT
Indicate how you wish to receive your withdrawal payment, if applicable, by selecting one of the options below. If no option is selected,
a check will be sent to your address of record.

A. Direct the distribution to my Fidelity nonretirement account:
Fidelity account number
AND
Fund name or symbol (for Fidelity Mutual Fund nonretirement accounts only)

B. Deposit electronically to my bank using Electronic Funds Transfer (EFT). (Note: You must already have EFT established to use this method. If you
have more than one bank linked to your Fidelity IRA, please indicate the bank below (SIGNATURE GUARANTEE REQUIRED only for withdrawals
requests of greater than $100,000).
Bank name ABA routing number Account number
Please allow two to three days for my funds to reach your bank.

C. By check to my address of record.
D. By check to a different address (SIGNATURE GUARANTEE REQUIRED):
Street address
City State ZIP
006940302
Page 2 of 4
1.738841.112
5
TAX WITHHOLDING ELECTIONS
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. 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 for Method 2 in Section 3, unless
you indicate a higher percentage below. For Method 1 in Section 3, Fidelity will withhold 10% of the earnings, if applicable, attributed
to the excess contribution, unless you indicate otherwise. See “State Tax Withholding — IRA Withdrawals” on the last page of this form.
Check one in each column. IRA owner’s legal/residential address determines which state’s tax rules apply.
Federal
Do NOT withhold federal taxes.
Withhold federal taxes at the rate of: %.
(Minimum 10%, maximum 99%. Whole numbers, no dollar
amounts. Note that if there is federal withholding, certain states
require that there also be state withholding.)
State
Do NOT withhold state taxes unless required by law.
Withhold state taxes at the applicable rate.
Withhold state taxes at the rate of: %.
(Maximum 99%. Whole numbers, no dollar amounts.)
006940303
Page 3 of 4
1.738841.112
6
SIGNATURE IS REQUIRED
Please read this section, sign in ink, and obtain a signature guarantee if you chose to have a check sent to you at an address
different from your address of record.
I authorize and request that Fidelity Management Trust Company, as Custodian of my Fidelity IRA (or its agents, affiliates, successors, or employees)
execute the instructions I have provided above. If I have elected to correct an excess contribution by treating such contribution as an annual contri-
bution for a subsequent year, I certify that I am eligible to make an annual contribution for that year. I accept full responsibility for complying with
IRS requirements for excess contributions, and I indemnify the Custodian for the Fidelity IRA, its agent(s), successors, affiliates, and employees from
liability in the event that I fail to meet these requirements.
If I am a U.S. citizen or other U.S. person (including a resident alien individual), I hereby certify, under the penalties of perjury, that the number
shown on this form is my correct Social Security number. If I am not a U.S. person (including a resident alien individual), I have attached IRS Form
W-8BEN with this IRA Return of Excess Contribution Request and have included my U.S. taxpayer identification number in order to claim tax treaty
benefits, if applicable.
SIGNATURE PRINT NAME DATE (mm/dd/yyyy)
SIGNATURE GUARANTEE STAMP DATE (mm/dd/yyyy)
Signature Guarantee Information
A signature guarantee is required if your withdrawal
exceeds $100,000, your current address of record
has been on file less than 15 days, or a check is being
sent to an address other than your address of record.
A signature guarantee is designed to protect you and
Fidelity from fraud. You should be able to obtain a
signature guarantee from a bank, broker, broker/dealer,
credit union (if authorized under state law), securities
exchange or association, clearing agency, or savings asso-
ciation. A notary public cannot provide a signature guar-
antee, and a notarization cannot be accepted in lieu of a
signature guarantee.
455267.4.0 C508-FORM-0612
1.738841.112
Fidelity Distributors Corporation
Retirement Distributions, P.O. Box 770001, Cincinnati, OH 45277-0035
Fidelity Brokerage Services LLC, Member NYSE, SIPC
Fidelity Investments is a registered service mark of FMR LLC.
Questions? Go to Fidelity.com or call 1-800-544-6666.
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
penalties for insufficient withholding.
• Withholding taxes for Roth IRA distributions is optional.
Withholding Options
State of residence State tax withholding options
AK, FL, HI, MS, 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, 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.
DE
• 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.
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 mini
mum 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 mini
mum 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 nondeductible 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 nontaxable amounts, you
must complete a separate distribution request form for each and complete the Tax
Withholding Election sections of the forms, as appropriate.
MI
• MI generally requires state income tax of at least your state’s minimum require
ments regardless of whether or not federal income tax is withheld.
• Tax withholding is not required if you meet certain MI requirements governing
pension and retirement benefits. Please reference the MI W4P Form for additional
information about calculating the amount to withhold from your distribution.
• Contact your tax advisor or investment representative for additional information
about MI requirements.
All other states
• State tax withholding is voluntary and you can choose the rate you want (any
whole number between 1% and 99%).
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.
006940304
Page 4 of 4
1.738841.112
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IRA Return Excess Contribution Request (Fidelity Investments)

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