Fillable Ny Beneficiary /BOSTON/xinet/ Bos Work/ Jobs/ 2019/37652/PIECE38/37652 38 FRM RRA Bene Fill (Fidelity Investments)

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Ny Beneficiary /BOSTON/xinet/ Bos Work/ Jobs/ 2019/37652/PIECE38/37652 38 FRM RRA Bene Fill (Fidelity Investments)

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Questions about your annuity? Call 800-634-9361.
Beneficiaries – Retirement Reserves Annuities (issued in New York)
Use this form to add or change the annuitant or owner beneficiaries of your Retirement Reserves annuity contract (issued in New
York only). Type on screen or print out and fill in. For best results, use CAPITAL letters and black ink. If you need more room for information
or signatures, make a copy of the relevant page or use a blank sheet.
Helpful to Know
• File one form per contract. If you have multiple
contracts, complete a separate form for each contract.
• For Custodial Contracts, the minor’s estate must be
the primary annuitant beneficiary.
• You may want to review this document with a tax,
financial, or legal advisor.
• Any new information you provide replaces information
we have on file. If updating annuitant beneficiary
information, be sure to list ALL the annuitant’s primary
AND contingent beneficiaries, and also do so if updating
owner beneficiaries.
• If you are receiving annuity income payments on your
Retirement Reserves contract, use the Beneficiaries —
Annuities form instead to complete your
beneficiary changes.
1. Contract Owner(s)
Contract Owner Name
Joint Contract Owner Name if applicable
Trust or Entity Name if applicable
2. Contracts Included
Annuity Contract Number Annuity Contract Number Annuity Contract Number
Annuity Contract Number Annuity Contract Number Annuity Contract Number
Trust and UGMA/
UTMA Accounts:
Provide names
of authorized
individuals in the
Contract Owner fields.
List all contracts you
want this form to apply
to. To indicate different
beneficiaries for
different contracts, use
copies of this form.
1.928023.105 Page 1 of 4 026260401
Form continues on next page.
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3. Annuitant Beneficiaries
Primary Beneficiaries
Name of Person, Trust, or Entity Phone
Address Street, City, State, ZIP Code Relationship
Social Security or Taxpayer ID Number Date of Birth or Trust MM DD YYYY Share Percentage
Per stirpes
%
Name of Person, Trust, or Entity Phone
Address Street, City, State, ZIP Code Relationship
Social Security or Taxpayer ID Number Date of Birth or Trust MM DD YYYY Share Percentage
Per stirpes
%
Name of Person, Trust, or Entity Phone
Address Street, City, State, ZIP Code Relationship
Social Security or Taxpayer ID Number Date of Birth or Trust MM DD YYYY Share Percentage
Per stirpes
%
Total must add up to 100%
%
Contingent Beneficiaries
Name of Person, Trust, or Entity Phone
Address Street, City, State, ZIP Code Relationship
Social Security or Taxpayer ID Number Date of Birth or Trust MM DD YYYY Share Percentage
Per stirpes
%
Name of Person, Trust, or Entity Phone
Address Street, City, State, ZIP Code Relationship
Social Security or Taxpayer ID Number Date of Birth or Trust MM DD YYYY Share Percentage
Per stirpes
%
Name of Person, Trust, or Entity Phone
Address Street, City, State, ZIP Code Relationship
Social Security or Taxpayer ID Number Date of Birth or Trust MM DD YYYY Share Percentage
Per stirpes
%
Total must add up to 100%
%
If you need more room for additional annuitant beneficiaries, make a copy of this page or use a blank sheet.
For each beneficiary
listing, provide all
required information.
If you want a
beneficiary’s share
to go to his or her
legal descendants
(biological or legally
adopted children) in
the event that you
outlive the beneficiary,
check “per stirpes.”
For jointly owned
Retirement Reserves
contracts, to continue
the contract upon
either owner’s death,
the joint owner must
be listed as the
annuitant primary
beneficiary.
Do NOT list
any primary
beneficiaries here.
Contingent
beneficiaries receive
assets if no primary
beneficiaries
survive you.
1.928023.105 Page 2 of 3 026260402
Form continues on next page.
4. Owner Beneficiaries
Primary Beneficiaries
Name of Person, Trust, or Entity Phone
Address Street, City, State, ZIP Code Relationship
Social Security or Taxpayer ID Number Date of Birth or Trust MM DD YYYY Share Percentage
Per stirpes
%
Name of Person, Trust, or Entity Phone
Address Street, City, State, ZIP Code Relationship
Social Security or Taxpayer ID Number Date of Birth or Trust MM DD YYYY Share Percentage
Per stirpes
%
Name of Person, Trust, or Entity Phone
Address Street, City, State, ZIP Code Relationship
Social Security or Taxpayer ID Number Date of Birth or Trust MM DD YYYY Share Percentage
Per stirpes
%
Total must add up to 100%
%
Contingent Beneficiaries
Name of Person, Trust, or Entity Phone
Address Street, City, State, ZIP Code Relationship
Social Security or Taxpayer ID Number Date of Birth or Trust MM DD YYYY Share Percentage
Per stirpes
%
Name of Person, Trust, or Entity Phone
Address Street, City, State, ZIP Code Relationship
Social Security or Taxpayer ID Number Date of Birth or Trust MM DD YYYY Share Percentage
Per stirpes
%
Name of Person, Trust, or Entity Phone
Address Street, City, State, ZIP Code Relationship
Social Security or Taxpayer ID Number Date of Birth or Trust MM DD YYYY Share Percentage
Per stirpes
%
Total must add up to 100%
%
If you need more room for additional owner beneficiaries, make a copy of this page or use a blank sheet.
For each beneficiary
listing, provide all
required information.
If you want a
beneficiary’s share
to go to his or her
legal descendants
(biological or legally
adopted children) in
the event that you
outlive the beneficiary,
check “per stirpes.”
For jointly owned
Retirement Reserves
contracts, to continue
the contract upon
either owner’s death,
list the owner that is
also the annuitant as
the owner primary
beneficiary.
Do NOT list
any primary
beneficiaries here.
Contingent
beneficiaries receive
assets if no primary
beneficiaries
survive you.
1.928023.105 Page 3 of 3 026260403
Signature and Date on next page.
1.928023.105 Page 4 of 4 026260404
Fidelity insurance products are issued by Fidelity Investments Life Insurance Company (FILI) and, in New
York, by Empire Fidelity Investments Life Insurance Company,
®
New York, N.Y. FILI is licensed in all states
except New York. A contract’s financial guarantees are subject to the claims-paying ability of the issuing
insurance company.
Fidelity Brokerage Services LLC, Member NYSE, SIPC. 580832.7.0 (06/19)
Did you print the form and did all owners sign it? Send the ENTIRE
form to Fidelity Investments. After the changes are registered, you will
receive a Revised Annuity Profile.
Regular Mail Overnight Mail
Annuity Service Center
PO Box 770001
Cincinnati, OH 45277-0051
Fidelity Investments
100 Crosby Parkway, KC2Q
Covington, KY 41015
5. Signature and Date Required. ALL Contract owners must sign and date.
By signing below, you:
• Acknowledge that the information in this
form replaces any and all beneficiary
information that may be on record for this
annuity at the time this form is received in
good order by Fidelity.
• Acknowledge and agree to all terms in the
contract concerning beneficiaries.
• Acknowledge that only those beneficiaries
who are alive on the contract owner’s death
(“date of death”) will receive the assets of
your contract.
• Acknowledge that Fidelity has no
responsibility for the application of
assets distributed to beneficiaries.
• Agree that by checking the “per stirpes”
box next to a beneficiary’s name, any sum
payable to that beneficiary will be divided
equally among the beneficiary’s surviving legal
descendants, if the beneficiary him- or herself
is no longer living on the date of death.
• Acknowledge that “per stirpes” creates
a category of beneficiaries (for example,
the children of your daughter or son), and
therefore may end up including individuals
who are not yet born or adopted.
• Acknowledge that if no percentages are
indicated, assets will be divided equally
among primary beneficiaries that are living
or have per stirpes descendants.
• Acknowledge that listing beneficiaries
by name does NOT create a category,
and that if you later want to include other
beneficiaries (such as any children born to
or adopted by you in the future), you will
need to file a new beneficiary form with
updated names and information.
• Agree that Fidelity has no obligation to
locate any beneficiary, notify any person
of any transfer of assets to beneficiaries,
or to independently verify any information
submitted by any person claiming an
interest in your contract.
• Certify that for Fidelity-issued trust-owned
annuities (excluding charitable remainder
trusts), all beneficiaries are natural persons.
PRINT CONTRACT OWNER/TRUSTEE NAME
CONTRACT OWNER/TRUSTEE SIGNATURE DATE MM/DD/YYYY
SIGN
X X
PRINT JOINT CONTRACT OWNER NAME
JOINT CONTRACT OWNER SIGNATURE DATE MM/DD/YYYY
SIGN
X X
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Ny Beneficiary BOSTONxinet Bos Work Jobs 201937652PIECE3837652 38 FRM RRA Bene Fill (Fidelity Investments)

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Completed 19 July 2020

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