Fillable New Fidelity Account IRA Helpful to Know Important (Fidelity Investments)

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New Fidelity Account IRA Helpful to Know Important (Fidelity Investments)

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Page 1 of 9
Questions? Go to Fidelity.com/openaccount or call 800-343-3548.
New Fidelity Account
®
— IRA
Complete this application to open a Traditional, Rollover, or Roth IRA. Do NOT use this form for SEP, SIMPLE, or Inherited IRAs. If
you want to initiate a rollover and you do not yet have a rollover check, call Fidelity. Type on screen or print out and fill in using CAPITAL
letters and black ink. If you need more room for information or signatures, make a copy of the relevant page.
Important to Understand
By signing this application, you acknowledge that:
• Fidelity Brokerage Services LLC (“FBS”) will perform
brokerage and administrative services.
• National Financial Services LLC (“NFS”) will maintain the assets
in a brokerage account and provide administrative services.
• Fidelity Management Trust Company (“FMTC”) will act as
IRA Custodian.
• FBS, NFS, and FMTC are together referred to herein as “Fidelity.”
• Uninvested money in your account is held in your Core Position
(“Core Position”) until you direct otherwise.
• Important documents related to your account include the Fidelity
IRA Custodial Agreement and Disclosure Statement or Fidelity
Roth IRA Custodial Agreement and Disclosure Statement and
Fidelity Brokerage Retirement Account Customer Agreement
(“Customer Agreement”), and other relevant information
delivered from time to time.
Helpful to Know
Regarding this account:
• Please understand that you are responsible for maintaining your
five-year aging date and related IRS reporting for qualified
Roth distributions.
• If you elect to roll over your deceased spouse’s IRA assets to your
own IRA, please contact Fidelity to address any remaining year-
of-death required minimum distribution (“RMD”) amounts.
• For additional information or for help filling out this application,
please call a Fidelity Representative at 800-343-3548.
1. Account Type
You may open more than one type of account at the same time. For more about account types, go to Fidelity.com/openaccount.
Traditional IRA Rollover IRA Roth IRA
2. Account Owner
First Name Middle Name Last Name
Date of Birth MM DD YYYY Email
Social Security or Taxpayer ID Number Daytime Phone Extension
Residential Address (where you live) This is your legal address used for tax reporting.
Street Address
City State ZIP Code
Mailing Address This may be a P.O. box, drop box, or c/o location.
Same as residential address
Default if no other information indicated below.
Mailing Address
City State ZIP Code
Check all that apply.
1.930461.116 002192501
Account Owner continues on next page.
Enter full name as
evidenced by a
government-issued,
unexpired document
(e.g., driver’s license,
passport, permanent
resident card).
Print
Reset
Save
Page 2 of 9
Citizenship
U.S. citizen
Foreign citizen Information in this box must be completed.
Permanent U.S. resident Non-permanent U.S. resident Nonresident of U.S.
Country of Citizenship Country of Tax Residency Only applicable to nonresidents of the U.S.
City, State/Province, and Country of Birth
Passport
DHS Permanent Resident Card
Employment Authorization Document
Foreign National Identity Document
Income Source Industry regulations require us to ask for this information.
Employed Self-employed
Occupation Employer Leave blank if self-employed.
Employer Address
City State/Province ZIP/Postal Code Country
Retired Not employed
Source of Income Pension, investments, spouse, etc.
Associations
If you are employed by or associated with a broker-dealer, stock exchange, exchange member firm, the Financial
Industry Regulatory Authority (FINRA), a municipal securities dealer, or other financial institution, or are the spouse or
an immediate family member residing in the same household of someone who meets the aforementioned employ-
ment criteria, provide the company’s name and address below. By providing this information and completing this form,
you hereby authorize Fidelity to provide the associated person’s employer with duplicate copies of confirmations and
statements, or the transactions data contained therein, for your account(s) and any accounts you choose to have on a
consolidated statement for purposes of their compliance review.
Company Name
Company Address
City State/Province ZIP/Postal Code Country
Affiliations
If you, your spouse, or any of your relatives (including parents, in-laws, and/or dependents, etc.), living in your home (at
the same address), is a member of the board of directors, a 10% shareholder, or a policy-making officer of a publicly
traded company (an “Affiliate”), you must provide the information below. If there are more than two Affiliates, make a
copy of this section.
Affiliate’s Company Name Trading Symbol or CUSIP
Affiliate’s Company Name Trading Symbol or CUSIP
Indicate your
citizenship status.
Check one and attach
a copy of a valid and
unexpired government ID
showing number and photo.
To claim non-U.S. tax status,
also complete and submit an
IRS Form W-8BEN.
Check one and
provide information.
As a person associated
with a member firm, you
are obligated to receive
consent from that firm.
Fidelity has existing
consent agreements
with many firms for
their employees to
maintain accounts with
Fidelity and to deliver
transactional data. If
your firm is not one
of them, Fidelity will
attempt to contact your
firm’s compliance office.
1.930461.116 002192502
2. Account Owner, continued
Form continues on next page.
Page 3 of 91.930461.116 002192503
3. Core Position
Your core position (“Core Position”) is where your money is held until you invest it. For your Core Position, please select from the options listed below.
Fidelity Government Money Market Fund (SPAXX)
Default if no choice is indicated.
FDIC-Insured Deposit Sweep (For more information, see the FDIC-Insured Deposit Sweep Program Disclosure)
There may be other options available for your Core Position in addition to the ones listed above. If so, you can change your Core Position
to one of these other options after your account is opened. For more information about how to do this, please contact Fidelity. In certain
circumstances, such as when Fidelity determines that you reside outside the United States, the Core Position will operate differently. Please
refer to the Customer Agreement for further details.
4. Initial Funding — Traditional and Roth IRAs Only This is a one-time contribution.
Check all funding options that apply. For annual contributions, do not exceed the applicable IRS maximum. For more about contribution
limits, go to Fidelity.com/ira/contribution-limits. Prior year contributions must be made by the tax filing deadline (usually April 15 of the
following year). To find additional forms mentioned below, go to Fidelity.com/forms. For other funding options, call Fidelity.
One-time Annual Contribution
By check payable to Fidelity Brokerage Services LLC. We cannot accept third-party checks. Indicate the year for which
you are contributing on the front of your check. If no year is indicated, we will credit for the current calendar year.
From a Fidelity non-retirement account:
Indicate amount if a portion is being transferred. If entire account value is transferred, the source account will be closed. Account
features do not transfer and must be reestablished for the new account.
Contribution Year
Fidelity Non-Retirement Account Number Amount Must be available as cash.
$
.
Fidelity Fund Name For mutual fund accounts only. Position will be liquidated/sold and proceeds will be contributed as cash.
Contribution Year
Fidelity Non-Retirement Account Number Amount Must be available as cash.
$
.
Fidelity Fund Name For mutual fund accounts only. Position will be liquidated/sold and proceeds will be contributed as cash.
Transfer from an Existing IRA of the Same Registration Type
Transfer from an IRA at another firm
Include a completed Transfer of Assets form.
Transfer from another Fidelity IRA:
Fidelity IRA Account Number Amount Must be available as cash.
OR
$
All Assets
.
Roth Conversion of a Fidelity IRA
Fidelity IRA to Fidelity Roth IRA conversion
Include a completed Fidelity Roth IRA Conversion form.
Your name and
SSN must be
identical on both
accounts.
Your name and
SSN must be
identical on both
accounts.
Form continues on next page.
Page 4 of 91.930461.116 002192504
5. Initial Funding — Rollovers Only This is a one-time contribution.
Enclose a copy of a recent employer-sponsored retirement plan statement for each rollover. This will help us process your rollover as
quickly and accurately as possible.
Approximate Amount Statement Enclosed Funding Method
See options below
Rollover 1:
Amount
$
.
Yes 1 2
Rollover 2:
Amount
$
.
Yes 1 2
1. Funding a Rollover Distribution with Funds You Have Already Withdrawn and Payable to You
1. Funds already withdrawn from the plan sponsor
Check must be written by you, as third-party checks cannot be accepted.
2. Check should be made payable to Fidelity Management Trust Company
3. Mail check to: Fidelity Management Trust Company Corporate Rollover Department
P.O. Box 770001
Cincinnati, OH 45277-0037
2. Funding a Rollover Distribution with Funds Held by the Employer Sponsor
Funds have been requested from your previous employer(s), but they need information from Fidelity. Please
contact the firm where your assets are held
.
Plan Administrator
Administrator Name
Mailing Address
City State ZIP Code
Plan/Account Number
Plan Administrator
Administrator Name
Mailing Address
City State ZIP Code
Plan/Account Number
Firm where assets
are now
Firm where assets
are now
Form continues on next page.
0021925051.930461.116 Page 5 of 9
Form continues on next page.
6. Ongoing Funding Options
Electronic Funds Transfer (EFT)
EFT allows you to electronically transfer funds between your bank or other financial institution and Fidelity. This section must be completed
for automatic investments from outside Fidelity. Not ready to sign up now? Log in to Fidelity.com/eft after your account has been opened
to establish EFT.
You must be an owner of the account at the other financial institution. You will need to attach a voided check, deposit slip, or bank statement
with the account number and all owner names preprinted on it.
Checking
Savings
Provide bank information below to set up the EFT feature.
Owner(s) Name(s) Exactly as on Bank Account
Bank Routing/ABA Number
Bank Name
Checking or Savings Account Number
Automatic Investments
Automatic Investments may be set up at any time to direct Electronic Funds Transfer that are held in your Core Position into the
investment vehicle of your choice. This can be established by visiting Fidelity.com/AutoInvest.
7. Account Features
Account features are available for your new account. You may establish most of these online at Fidelity.com/updateaccountfeatures. Or, you
may choose from the following:
Automatic Contributions
Adding automatic contributions to your account allows you to automatically invest in eligible Fidelity and Fidelity
FundsNetwork funds based on a schedule you determine. This can be established by visiting Fidelity.com/AutoInvest.
Be aware that you must also sign up for EFT in order to use this feature.
Active Trader
Request Active Trader
To sign up later, call a trading specialist at 800-564-0211.
Trades per year: 36–119 120+
Electronic or Paper
If you provided an email address in Section 2 and unless you indicate otherwise below, all materials will be sent to you electronically. To
confirm electronic delivery, respond to the Electronic Delivery Agreement and Consent, which we will email to you.
I choose to receive the following by U.S. mail:
Account statements
Other documents (including shareholder reports and regular prospectus mailings)
Trade confirmations and related prospectuses
Tax forms and related disclosures
Check only those items
you do NOT want to
receive electronically.
Page 6 of 9 0021925061.930461.116
8. Beneficiaries
You may want to review this document with a tax, financial, or legal advisor. Designating beneficiaries is optional. However, leaving this section
blank will indicate that no beneficiary is named by you for this account and that upon your death, payment will be made according to the rules
of succession as outlined in the applicable Custodial Agreement. You can add or change beneficiaries any time at Fidelity.com/beneficiary.
Copy Beneficiaries from Another Fidelity IRA Account
Available ONLY if you want to copy the current beneficiary designation(s) from an existing Fidelity IRA that does NOT have customized beneficiaries.
Designate the SAME beneficiaries
and percentages on this account
as are currently designated for:
Your Existing Fidelity IRA Account Number
Skip to next section.
Primary Beneficiaries
Spouse
Non-Spouse
Name If naming spouse as a beneficiary, do so here.
Trust
Other Entity
Social Security or Taxpayer ID Number Date of Birth/Trust MM DD YYYY Share Percentage
Per stirpes
%
Non-Spouse
Trust
Other Entity
Name
Social Security or Taxpayer ID Number Date of Birth/Trust MM DD YYYY Share Percentage
Per stirpes
%
Non-Spouse
Trust
Other Entity
Name
Social Security or Taxpayer ID Number Date of Birth/Trust MM DD YYYY Share Percentage
Per stirpes
%
Non-Spouse
Trust
Other Entity
Name
Social Security or Taxpayer ID Number Date of Birth/Trust MM DD YYYY Share Percentage
Per stirpes
%
Total must add up to 100%.
%
For each beneficiary
you list by name,
check a beneficiary
type and provide
all information.
If you outlive a
beneficiary and you
want that benefi-
ciary’s share to go
to each of his or her
descendants by right
of representation,
check “per stirpes.”
Beneficiaries continues on next page.
0
1.930461.116 Page 7 of 9 002192507
Contingent Beneficiaries
Spouse
Non-Spouse
Name If naming spouse as a beneficiary, do so here.
Trust
Other Entity
Social Security or Taxpayer ID Number Date of Birth/Trust MM DD YYYY Share Percentage
Per stirpes
%
Non-Spouse
Trust
Other Entity
Name
Social Security or Taxpayer ID Number Date of Birth/Trust MM DD YYYY Share Percentage
Per stirpes
%
Non-Spouse
Trust
Other Entity
Name
Social Security or Taxpayer ID Number Date of Birth/Trust MM DD YYYY Share Percentage
Per stirpes
%
Non-Spouse
Trust
Other Entity
Name
Social Security or Taxpayer ID Number Date of Birth/Trust MM DD YYYY Share Percentage
Per stirpes
%
Total must add up to 100%.
%
9. Signature and Date Account owner must sign and date.
Please be sure to read all the language included in the following pages, as well as sign, date, and return all pages of
this application (1–9) to Fidelity.
To help the government fight financial crimes, federal regulation requires Fidelity to obtain your name, date of birth, address, and a
government-issued ID number before opening your account, and to verify the information. In certain circumstances, Fidelity may obtain
and verify comparable information for any person authorized to make transactions in an account. Also, federal regulation requires Fidelity
to obtain and verify the beneficial owners and control persons of legal entity customers. Requiring the disclosure of key individuals who
own or control a legal entity helps law enforcement investigate and prosecute crimes. Your account may be restricted or closed if Fidelity
cannot obtain and verify this information. Fidelity will not be responsible for any losses or damages (including, but not limited to, lost
opportunities) that may result if your account is restricted or closed.
You acknowledge that this account is governed by a predispute arbitration clause, which appears on the last page of the Customer
Agreement and that you have read the predispute arbitration clause.
By signing below, you acknowledge that you have read, understand, and agree to be bound by the provisions of this application,
including the Terms and Conditions for this Account on the next page.
PRINT OWNER NAME
OWNER SIGNATURE
SIGN
X
TODAY’S DATE MM/DD/YYYY
DATE
X
587469.18.0
Contingent beneficia-
ries receive assets only
if no primary beneficiary
survives you.
Do NOT list any primary
beneficiaries here.
Form continues on next page.
8. Beneficiaries, continued
0
10. Terms and Conditions
By signing the previous section, you:
• Adopt the Fidelity IRA or Fidelity Roth IRA
selected in Section 1 and appoint FMTC
(or its successor) as Custodian, and FBS
and NFS to perform administrative services
pursuant to the terms of the Fidelity IRA or
Roth IRA Custodial Agreement.
• Acknowledge that you received the
Customer Agreement, the Fidelity IRA
Custodial Agreement and Disclosure
Statement, and the Fidelity Roth IRA
Custodial Agreement and Disclosure
Statement, that you have read and under-
stand both the Customer Agreement and
the applicable Custodial Agreement(s) that
apply to the account(s) you are opening
with this application, and that you agree to
all terms and conditions on this application
and in the above agreements, as these
agreements may be amended from time
to time.
• Acknowledge that acceptance of your
application will be indicated by a Letter
of Acceptance signed by, or on behalf
of, Fidelity or its agent, and delivered
upon the Custodian’s receipt of the initial
contribution.
• Acknowledge that FMTC’s acceptance of
its appointment as Custodian is effective
upon proper completion and signature
of the application, and contingent upon
timely delivery of this application, as signed
and properly completed, to the Custodian,
notwithstanding what is stated in Article
8, Section 27, of the Fidelity IRA Custodial
Agreement and Article 9, Section 26, of the
Fidelity Roth IRA Custodial Agreement,
as appropriate.
• Understand that Fidelity may charge an
annual maintenance fee and/or liquidation
fee and this fee may be separately billed or
collected by liquidating sufficient securities
from your account. Fidelity may change the
fee schedule from time to time, as provided
in the Fidelity IRA Custodial Agreement.
• Agree to indemnify the Custodian (its
agents, affiliates, successors, and employ-
ees) from any and all liability in the event
that you fail to meet any IRS requirements
concerning your IRA(s).
• Acknowledge that payment to beneficia-
ries will be made according to the rules
of succession described in the applicable
Custodial Agreement.
• Agree that to the extent that inherited
employer-sponsored plan assets are being
directly rolled to an IRA or Inherited IRA,
you understand that it is your responsibility
to ensure that only eligible assets are rolled
and all required minimum distributions
are satisfied.
• Agree that upon transfer of assets due to
any life event (divorce, death, etc.), and
unless otherwise instructed, all residual
income paid to the account and any frac-
tional shares will be systematically allocated
to the Transferee (New Asset Holder)
receiving the largest share proportion of
the account assets. If the account is
transferred evenly, or at different intervals,
the income and/or fractional shares will
be systematically allocated to the last
transferee paid.
• Affirm that you have received and read
the Schedule of Fees, that you understand
this schedule may change from time to
time, and that you agree to be responsible
for those fees and charges that apply to
your account.
• Affirm that you are at least 18 years old and
of full legal age to enter into the agree-
ments associated with this application in
your state of residence.
• Represent and warrant that if you have not
completed the section titled Associations,
you are not employed by nor associated
with a broker-dealer, stock exchange,
exchange member firm, FINRA, a municipal
securities dealer, nor any other financial
institution, nor are you the spouse or imme-
diate family member residing in the same
household of such a person.
• Represent and warrant that if you have not
completed the section titled Affiliations,
none of you, your spouse, nor any of your
relatives living in your home are a control
person or affiliate of a public company
under SEC Rule 144.
• Acknowledge that you agree to the use
of the Core Position to hold any assets of
your account pending investment or other
instructions and that you have received and
read the prospectus or other applicable
documents for the Core Position.
• Affirm that you have received the FDIC-
Insured Deposit Sweep Program Disclosure
and that you have read and understand this
disclosure document.
• Acknowledge that if no choice is indicated,
the default Core Position will be the core
account indicated in the Core Position
section of the application.
• Understand that if your Core Position is
the money market fund, you could lose
money by investing in it. Although the
fund seeks to preserve the value of your
investment at $1.00 per share, it cannot
guarantee it will do so. An investment
in the fund is not insured or guaran-
teed by the Federal Deposit Insurance
Corporation or any other government
agency. Fidelity Investments and its affil-
iates, the fund’s sponsor, have no legal
obligation to provide financial support
to money market funds and you should
not expect that the sponsor will provide
financial support to the fund at any time.
• Understand that Fidelity’s government and
U.S. Treasury money market funds will not
impose a fee upon the sale of your shares,
nor temporarily suspend your ability to sell
shares if the fund’s weekly liquid assets fall
below 30% of its total assets because of
market conditions or other factors.
• Acknowledge that you have received the
description of the Core Account in the
Customer Agreement, including Fidelity’s
right to change the options available as
core positions, and consent to having free
credit balances held or invested in the Core
Position indicated above.
• Consent to have only one copy of Fidelity
mutual fund shareholder documents, such
as prospectuses and shareholder reports
(“Documents”), delivered to you and
any other investors sharing your address.
Your Documents will be householded
indefinitely; however, you may revoke this
consent at any time by contacting Fidelity
at 800-343-3548 and you will begin receiv-
ing multiple copies within 30 days. As
Documents for other investments become
available in the future, these Documents
may also be householded in accordance
with this authorization or any notice or
agreement you received or entered into
with Fidelity or its service providers.
• Understand that, upon an issuer’s request
in accordance with applicable rules and
regulations, Fidelity will supply your name
to issuers of any securities held in your
account so you might receive any import-
ant information regarding them, unless you
notify Fidelity.
1.930461.116 Page 8 of 9 002192508
Terms and Conditions continues on next page.
1.930461.116 Page 9 of 9 002192509
• Understand that it is your responsibility
to read the prospectus for any security
purchased for your account or into which
your holdings are exchanged, including
the Core Position.
• Certify that all information you provided is
true, accurate, and complete.
• Acknowledge that Fidelity will not be liable
for any loss, cost, or expense arising out of
your instructions, provided that it institutes
reasonable procedures to prevent unautho-
rized transactions.
• Hereby constitute and appoint Fidelity your
true and lawful attorney to surrender for
redemption any and all shares held in the
above-indicated accounts with full power of
substitution in the premises.
• Acknowledge that Fidelity reserves the
right to cease to act as agent in connection
with the above appointment after provision
of notice to the address noted on this form.
• Agree that the certifications, authorizations,
and appointments in this document will
continue until Fidelity receives actual writ-
ten notice of any change thereof.
• Acknowledge that you will receive a
monthly account statement from Fidelity,
unless there are no transactions in a partic-
ular month. In any case, you will receive a
statement quarterly.
If requesting EFT:
• Acknowledge that you have read and
agree to the Important Information about
Electronic Funds Transfer document.
• Authorize Fidelity, upon receiving
instructions from you, to make payments
of amounts representing redemptions by
you or distributions payable to you by
initiating credit or debit entries to the bank
account identified in Section 5 (Bank). You
authorize and request the Bank to accept
such entries from Fidelity, and to credit or
debit, as indicated, your account at the
Bank in accordance with these entries.
• Understand that there is no fee to use
the EFT service, although your financial
institution may charge transaction fees.
• Acknowledge that this authorization may
only be revoked by providing written notice
of revocation to Fidelity, in such time and
manner as afford Fidelity and the bank a
reasonable opportunity to act upon it.
• Understand that Fidelity may purge unused
EFT instructions from my account on a
periodic basis without notice to me.
• Understand that Fidelity may terminate the
EFT instructions from my account at any
time in its sole discretion.
If you are not a U.S. person:
• State that you are submitting IRS Form
W-8 BEN with this application to certify
your foreign status and, if applicable, to
claim tax treaty benefits.
On this form, “Fidelity” means Fidelity Brokerage Services LLC and its affiliates. Brokerage services are
provided by Fidelity Brokerage Services LLC, Member NYSE, SIPC. 587469.18.0 (08/20)
Did you sign the application and attach a check or any necessary
documents? Send the ENTIRE application and any attachments to
Fidelity Investments. You will receive a “New Account Profile” confirming
that your account(s) is opened.
Questions? Go to Fidelity.com/openaccount or call 800-343-3548.
Regular mail
Fidelity Investments
P.O. Box 770001
Cincinnati, OH 45277-0002
Overnight mail
Fidelity Investments
100 Crosby Parkway KC1K
Covington, KY 41015
10. Terms and Conditions, continued
Page 1 of 2
Questions? Go to Fidelity.com/trustedcontact or call 800-343-3548.
Trusted Contact Authorization Form
Use this form to designate a primary and alternate trusted contact, that is 18 years or older, for your Fidelity account(s). Do NOT use
this form for charitable giving accounts or workplace retirement plans, such as a 401(k). 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
• To prepare yourself and your trusted contact(s) for success,
consider choosing someone with whom you are comfortable
discussing your health, relationships, loved ones, work,
and finances. You may also want to consider selecting
someone who isn’t currently involved in your financial life,
like a beneficiary or power of attorney, to ensure fairness
and objectivity.
• This form supersedes any previous trusted contact
designations that you may have submitted.
• If you are using this form for an Entity relationship (for ex: a
business account), we will assign the Trusted Contact(s) to the
Authorized Individual that signs this form.
• If Fidelity has questions or concerns about your health or welfare
due to potential diminished capacity, financial exploitation or
abuse, endangerment, and/or neglect, this form authorizes us to
get in touch with the trusted contact(s) and:
– Provide the trusted contact(s) listed below with information
about you and/or your account(s), including notice of a
temporary hold, but does not provide him or her with the
ability to transact on your account(s).
– Inquire about your current contact information or
health status.
– Inquire about whether another person or entity has legal
authority to act on your behalf (e.g., legal guardian or
conservator, executor, or trustee).
1. Account Owner
First Name Middle Name Last Name
Social Security or Taxpayer ID Number
2. Accounts Included
ALL eligible accounts associated with the above Social Security or Taxpayer ID Number
Skip to Section 3.
ONLY the account(s) listed below:
Fidelity Account Number Fidelity Account Number Fidelity Account Number
Fidelity Account Number Fidelity Account Number Fidelity Account Number
3. Primary Trusted Contact Name, email, phone, and address are all required.
First Name Middle Name Last Name
Email Relationship to Owner (Spouse, Child, Parent, Sibling, Friend, Other)
Primary Phone
Mobile
Number
Secondary Phone
Mobile
Number
Legal/Permanent Address
Street Address
City State/Province ZIP/Postal Code Country
Check only one.
The trusted contact
MUST be someone
other than the individual
listed in Section 1. Do
not provide the account
owner’s information here.
This cannot be a
PO box, mail drop,
or c/o.
1.9883825.102 037430201
Form continues on next page.
Page 2 of 21.9883825.102 037430202
4. Alternate Trusted Contact Name, email, phone, and address are all required.
First Name Middle Name Last Name
Email Relationship to Owner (Spouse, Child, Parent, Sibling, Friend, Other)
Primary Phone
Mobile
Number
Secondary Phone
Mobile
Number
Legal/Permanent Address
Street Address
City State/Province ZIP/Postal Code Country
5. Signature and Date Form cannot be processed without your signature and date.
By signing below, you:
• Authorize Fidelity to communicate with
your trusted contact(s) and disclose
information about designated accounts
to address possible financial exploitation
or confirm specifics about your current
contact information, your health status, or
the identity of any legal guardian, executor,
trustee, or holder of a power of attorney, or
as otherwise permitted.
• Understand that this does not authorize
your trusted contact(s) to separately access
or transact on your account(s).
• Understand that you may identify multiple
trusted contacts on this form, provided
they are 18 years or older.
• Understand that this trusted contact
designation is optional and you may
withdraw it at any time by notifying Fidelity
in writing to one of the business addresses
listed below.
• Understand that you may change
your trusted contact(s) at any time by
completing a new form.
• Certify that all information provided in this
form is true, accurate, and complete.
• Acknowledge that we may remove any
trusted contact from any account, at any
time or for any reason.
PRINT OWNER/AUTHORIZED INDIVIDUAL NAME
OWNER/AUTHORIZED INDIVIDUAL SIGNATURE DATE MM/DD/YYYY
SIGN
X X
The trusted contact
MUST be someone other
than the individuals listed
in Sections 1 and 3. Do
not provide the account
owner’s information here.
This cannot be a
PO box, mail drop,
or c/o.
On this form, “Fidelity” means Fidelity Brokerage Services LLC and its affiliates. Brokerage services are
provided by Fidelity Brokerage Services LLC, Member NYSE, SIPC. 802990.3.0 (06/20)
Did you sign the form? Send the ENTIRE form to Fidelity.
Questions? Go to Fidelity.com/trustedcontact or call 800-343-3548.
Regular mail
Fidelity Investments
PO Box 770001
Cincinnati, OH 45277-0002
Overnight mail
Fidelity Investments
100 Crosby Parkway KC1K
Covington, KY 41015
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New Fidelity Account IRA Helpful to Know Important (Fidelity Investments)

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Completed 5 February 2021

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