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Questions? Go to Fidelity.com/smallbusiness or call 800-343-3548.
One-Time Withdrawal – Investment-Only
(Non-Prototype) Retirement Account
Use this form to request a one-time, immediate distribution from an Investment-Only Retirement Account (also known as the
Fidelity Non-Prototype Account). Do NOT use this form for a Traditional, Rollover, Roth, SEP, SIMPLE, or Inherited IRA; annuities;
or nonretirement accounts. 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
• An Investment-Only Retirement Account provides an
investment vehicle for qualified retirement plan assets.
Fidelity does not provide plan document, trustee,
recordkeeping, tax-withholding, or tax-reporting services
for this type of account.
• Only plan trustees can request distributions from
the account.
• If the Investment-Only Retirement Account is a pooled
account, then the trustee must obtain a Medallion signature
guarantee for any distribution method other than a check
made payable to the employer’s retirement plan.
•
It is your responsibility to ensure that your distributions
comply with IRS rules and all plan requirements. You
should consult your third-party administrator and/or tax
advisor prior to taking a distribution to ensure that all
applicable recordkeeping, tax-reporting, and tax-
withholding requirements associated with the requested
withdrawal are met.
• If this form directs Fidelity to sell shares of any security, be
aware that the timing of the transaction depends on when
we receive this form, which is outside of your control. To
better control the timing of the transaction, you should
direct the sale of securities online or through a Fidelity
representative. Note: Certain securities (such as options,
certain fixed income securities, and thinly traded securities)
may not be eligible to sell via this form, which may result
in Fidelity not being able to process this withdrawal as
requested.
• Any fees charged or expenses incurred in connection with
your instructions will be assessed at the “rep-assisted”
rates. Fees and expenses may be lower if you instead place
your trades online. Please refer to the Schedule of Fees for
more information.
1. Plan and Trust Information
Account Number Name of Trustee
Name of Employer Plan
Name of Plan Participant If applicable
Daytime Phone Extension
2. Distribution Instructions
If this form directs Fidelity to sell shares of any securities (including mutual funds), be aware that:
• The timing of the transaction (i.e., when
your trade is processed) depends on
when we receive this form, which is
outside of your control.
• If you want to better control the timing
of the transaction, you should direct the
sale of securities online or through a
Fidelity representative.
• If you withdraw all assets from your
source account, that account will remain
open, unless you tell us otherwise by
checking the box below.
• Once we receive this form in good order,
you cannot cancel your distribution request.
Cash Distributions from a Brokerage Investment-Only Retirement Account
For any distribution that involves the sale of mutual fund shares (other than money market funds) or other
securities, skip to “All Other Types of Distributions.”
ALL core cash and Fidelity money market funds in your account.
Skip to Section 3.
Close your account.
ONLY the following amount of cash in your account:
Dollar Amount
Skip to Section 3.
$
This phone number
may be used if we have
questions, but will not
be used to update your
account information.
If the amount you
indicate is greater
than your core
account balance,
your request will
be denied.
1.923159.105 026500301
Distribution Instructions continues on next page.
