Fillable Retirement Plan Automatic Withdrawal Request (Fidelity Investments)

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Retirement Plan Automatic Withdrawal Request (Fidelity Investments)

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Page 1 of 6
Questions? Go to Fidelity.com/rmd or call 800-343-3548.
Automatic Withdrawals—Fidelity Retirement Plan
Use this form to request automatic withdrawals on a regular basis or to request Fidelity to calculate and establish a required minimum
distribution (RMD) plan for a Fidelity Self-Employed 401(k), Profit Sharing, or Money Purchase Plan account. Do NOT use this form for
a Traditional, Rollover, Roth, SEP, SIMPLE, or Inherited IRA; a nonretirement account; or an annuity. Go to Fidelity.com/forms to find the
appropriate form. Not available to nonresident aliens due to tax-withholding requirements. 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
• Only one automatic withdrawal plan is permitted
per account. To set up automatic withdrawal plans for
more than one account, complete a separate form
for each account.
• Distributions from the Fidelity Retirement Plan [i.e., Profit
Sharing, Money Purchase Plan, or Self-Employed 401(k)
Plan] are only permitted when a participant reaches
age 59½, separates from service, becomes disabled,
or dies, or the plan is terminated. Distributions for any
other reason may result in plan disqualification. You are
encouraged to consult your tax advisor regarding the tax
implications associated with each distribution.
• If you are terminating your plan, please note that plan
assets must be distributed as soon as administra-
tively feasible, generally within one year of the plan
termination effective date. To request a single distribu-
tion, complete the One-Time Withdrawal — Fidelity
Retirement Plan form. You should consult a tax advisor
to ensure that you have taken all the necessary steps to
properly terminate your plan.
• Distributions to married participants from any money
purchase plan and certain profit-sharing plans must be
made in the form of a joint and survivor annuity, unless
your spouse waives this right by providing spousal
consent in Section 8. Spousal consent is not required
for RMDs.
• For mutual funds, note that:
– Withdrawals could trigger redemption or transaction
fees (see the applicable fund prospectus).
– If a fund is closed to new investors, you will not be
able to purchase new shares of the fund in the future if
you draw your fund balance down to zero.
For RMD Plans
• For RMDs, return this form no later than November 30
or March 1, as applicable, to allow adequate time for
processing. Fidelity cannot assume responsibility for mak-
ing your distribution by the April 1 IRS deadline for your
initial RMD or the December 31 deadline for subsequent
year RMDs.
• It is your responsibility to ensure that your withdrawals
comply with IRS rules and deadlines for RMDs. You may
want to consult a tax advisor.
– For anyone who reached age 70½ in 2019 or before,
RMDs are required to begin by April 1 of the calendar
year after the calendar year in which you retire or reach
age 70½ (whichever is later) and must be taken annually
by each December 31 thereafter. For those who are
greater than 5% owners, RMDs must begin by April 1
of the calendar year after the calendar year in which
you reach age 70½ and must be taken annually by each
December 31 thereafter.
– Due to passage of the SECURE Act legislation, for those
turning 70½ in 2020 or after, the RMD age has been
increased to 72.
• Your RMD is calculated using assets in your Fidelity
Retirement Plan account [Money Purchase or Profit
Sharing, including Self-Employed 401(k)] as you have
specified on this form as of the prior December 31,
adjusted for outstanding rollovers and transfers if you
have specified that in the Calculation Adjustments sec-
tion. If you maintain Retirement Plan accounts at other
institutions, you are required to calculate your RMD for
your non-Fidelity Retirement Plan accounts separately.
• RMD amounts are generally calculated using the Uniform
Lifetime Table (applies a standard joint life expectancy
factor based on your age). The one exception applies
if your sole primary beneficiary is your spouse who is
more than 10 years younger than you. If so, the Spousal
Exception Joint Life Expectancy Table is used (applies a
joint life expectancy factor based on both your age and
your spouse’s age that will generally result in a lower RMD
amount). Both IRS tables are available online at Fidelity.com.
• At the beginning of each year, Fidelity determines which
IRS table to apply for the beneficiary designations on file
at that time. Important: Keep your beneficiary informa-
tion current to help ensure that proper calculations
are performed. Fidelity will not automatically update
your RMD plan until January of the year following the
year in which you make a beneficiary change. Note that
IRS rules generally permit the Spousal Exception Table
to be used only if your spouse is the sole primary ben-
eficiary for the entire year. Because of this, it may be
necessary for you to take an additional withdrawal to sat-
isfy your RMD in the year of a beneficiary change. Please
consult your tax advisor to determine how a beneficiary
change may affect your individual situation.
• Upon establishment of this Automatic Withdrawal Plan
and each year thereafter, you will be sent a Revised
Account Profile indicating the RMD amount to be
distributed under the plan for that year, and the Life
Expectancy Table that was used. If the Spousal Exception
is applied, the Account Profile will confirm the name and
date of birth of your spouse beneficiary.
1.749593.117 015400601
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Page 2 of 6
1. Account Owner
Name Fidelity Account Number
Social Security or Taxpayer ID Number Date of Birth MM DD YYYY
Type of Account Included
Money Purchase
Profit Sharing [includes Self-Employed 401(k)]
2. Request Type and Reason
Type of Request
ESTABLISH a new automatic withdrawal plan
CHANGE an existing automatic withdrawal plan
Type of Automatic Withdrawal Plan Examples: Fixed Dollar Amount, RMD
DELETE an existing automatic withdrawal plan
Type of Automatic Withdrawal Plan Examples: Fixed Dollar Amount, RMD
Reason for Distribution
Normal You are AT LEAST 59½ when your first distribution occurs.
Severance from employment You are younger than 59½ when your first distribution occurs, have no disability that meets
the IRS definition, and are not requesting substantially equal periodic payments (SEPPs). IRS early distribution penalty may apply.
Disability You are younger than 59½ at time of distribution. Must qualify under the Fidelity Retirement Plan definition of
“disability” as defined in Article 2.14 of the Fidelity Retirement Plan and Trust Agreement.
3. Select Your Automatic Withdrawal Plan Type
Fixed Dollar Amount
Amount
$
.
Required Minimum Distribution (RMD)
Calculation Adjustments
Provide the 12/31 market value of any assets that were in the process of being transferred or rolled over
to a Fidelity Retirement Plan last year, but were not included in last year’s 12/31 market value as reported
by Fidelity:
Amount
$
.
Reduce this year’s automatic distribution amount by the amount of the distributions already made this year, as
indicated below:
Amount
$
.
Check only one.
Check one.
If selected, skip to
Signatures and
Dates section.
Check one.
Check one.
Your RMD amount will
be calculated using
the account number
specified on the form.
Check one.
1.749593.117 015400602
Form continues on next page.
Automatic Withdrawals — Fidelity Retirement Plan, continued
Page 3 of 61.749593.117 015400603
4. Distribution Schedule
Distribution payments may be made earlier or later depending on market availability. Examples include payments that are
scheduled for a day when the stock market is closed or for a day that doesn’t exist in every month (29th–31st), or payments
scheduled close to the beginning or end of the year. For custom frequency options, call Fidelity. If no frequency is indicated,
you will receive annual distributions on the 5th of every December.
If you are setting up your withdrawal plan midyear to take an RMD, your entire RMD for the current year will be paid out evenly over the
remaining number of scheduled payments in the year.
Annually
Quarterly
Monthly
Start Date MM DD YYYY
First-Year RMD Optional. Complete only if you have selected the RMD option in Section 3.
For the year in which you reach RMD age, you may defer your first RMD until April 1 of the following year. If you are choosing this option for
your RMD plan, please make sure the start date above is a date after the date you indicate in this section. You may want to consult a tax advisor.
If you turned 70½ or retired, as applicable, in 2019, defer LAST year’s RMD until this date: Date must be on or before
April 1 of THIS year.
Date of Deferred First RMD MM DD YYYY
5. Funding Your Distribution
You can choose to fund your distribution in one of two ways, as described below. If your distribution is from a Fidelity managed account,
skip to Section 6.
Proportional Distributions
Distributions will be withdrawn from the Eligible Positions in the account identified in Section 1. Eligible Positions include your core
position (for brokerage Fidelity Retirement Plans), all Fidelity mutual funds, and those non-Fidelity mutual funds available through
Fidelity
®
FundsNetwork
®
where the mutual fund company has agreed to make the fund available for automatic distributions.
Distribute proportionally from all Eligible Positions in the account.
Default if no choice indicated.
Fixed Amount/Percentage Distributions
Liquidate and distribute ONLY from these positions in the amount or percentage listed:
For Fixed Dollar Amount plans only.
Core Position or Fund Name/Number Amount
OR
Percentage
$
.0%
.
Core Position or Fund Name/Number Amount
OR
Percentage
$
.0%
.
Core Position or Fund Name/Number Amount
OR
Percentage
$
.0%
.
Core Position or Fund Name/Number Amount
OR
Percentage
$
.0%
.
Core Position or Fund Name/Number Amount
OR
Percentage
$
.0%
.
Total
must add up to 100%.
.0%
Secondary Withdrawal Instructions for Fixed Amount/Percentage Distributions:
Will be used if there are insufficient funds in the above core position or fund name(s)/number(s); and will be distributed from any
Eligible Positions with the lowest value to the highest value.
Any core position, and then any non-core money market position(s)
Any core position, then any non-core money market position(s), and then any other mutual fund position(s)
Default if no choice indicated.
Check ONLY one and
provide start date.
All funds listed must
be held in the account
listed in Section 1.
Use the “Amount”
column ONLY if you
chose the “Fixed
Dollar Amount” option
in Section 3. The com-
bined total amount
must equal the amount
indicated in Section 3.
NOT applicable to
Fidelity managed
accounts.
Form continues on next page.
0
0154006041.749593.117 Page 4 of 6
6. Distribution Method
You must obtain a Medallion signature guarantee if directing to a Fidelity account of which you are not the owner, or if the requested per-
payment amount is over $100,000.
Directly deposited into a Fidelity nonretirement brokerage account. Deposits will be made the core position. Requires a
Medallion signature guarantee if going to an account of which you are not the owner.
Fidelity Nonretirement Account Number
Directly deposited into a Fidelity nonretirement mutual fund account. The first three characters of the account number
are 2 followed by two letters (example: 2AB-123456).
Fidelity Nonretirement Account Number Fidelity Fund Name or Symbol Mutual fund accounts ONLY.
Electronic funds transfer (EFT) to a bank or credit union account. To add EFT to an account, go to Fidelity.com/eft
or provide your bank information below. The Fidelity account and bank account must have one common owner. You must
attach a voided check, deposit slip, or bank statement with the account number and all owner names preprinted on it.
If EFT cannot be established for any reason, a check will be sent to your address of record.
Checking Savings
Owner(s) Name(s) Exactly as on Bank Account
Bank Routing /ABA Number Bank Name
Checking or Savings Account Number
Check mailed to the address of record
Default if no choice indicated or if we are unable to process your choice.
7. Tax Withholding
Mandatory 20% Withholding
Per IRS rules, you cannot elect out of the 20% federal tax withholding if your distribution is eligible to be rolled over/converted and you
have elected a different payment method. This mandatory withholding of 20% does not apply if you are taking your RMD.
Distributions not subject to the Mandatory 20% Withholding
For periodic withdrawals that are not subject to the 20% withholding as described above, such as RMDs, IRS regulations require federal tax
withholding to be based on the appropriate wage table, unless you elect not to have withholding apply. If federal income tax withholding
is applied to your distribution, state income tax may also apply. See “State Tax Withholding — Fidelity Retirement Plan Withdrawals”
included at the end of this form.
If you do not opt out of federal withholding, Fidelity will apply the appropriate wage table for your withholding. If you elect to have
withholding, Fidelity will apply the percentage you have elected.
Specify your tax withholding election. Federal and state tax withholding combined cannot total more than 99%. Only applicable if not
subject to mandatory withholding.
Federal
Do NOT withhold federal taxes
Withhold federal taxes at the rate of:
Percentage
Minimum 10%; maximum total 99%.
Whole numbers; no dollar amounts.
Note: If there is federal tax withholding,
certain states require that there also be
state tax 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:
Percentage
Maximum total 99%. Whole numbers;
no dollar amounts.
%
Check one and
provide any required
information.
If you ONLY have one
set of EFT instructions
already established for
the account referenced
in Section 1, check the
box and skip to Section 7.
Otherwise, complete the
entire section.
Provide bank information
ONLY if establishing
new EFT instructions OR
if you have multiple EFT
instructions available for
the account referenced in
Section 1.
Check one in
each column.
Account owner’s
legal/residential
address determines
which state’s tax
rules apply.
Form continues on next page.
1.749593.117 Page 5 of 6 015400605
8. Signatures and Dates Plan Administrator and Plan Participant must sign and date.
Who must sign?
The Plan Administrator must sign in 8a.
The Plan Participant must sign in 8b.
8a. Plan Administrator
If the participant is married, and spousal consent is necessary, this distribution form must be signed by the spouse in the presence of
a notary public in 8c.
Spousal consent is not required for an RMD.
Indicate the Plan Participant’s marital status:
Single Married
By signing below, you:
• Certify that this distribution is being made
pursuant to the terms and conditions of the
Fidelity Retirement Plan and Trust Agreement
and the instructions contained herein.
• Authorize and request the trustee of
the Fidelity Retirement Plan, Fidelity
Management Trust Company and its agents,
affiliates, employees, or successor custodians
(Fidelity), to make the above withdrawal.
• If this is a distribution from a Profit Sharing or
Self-Employed 401(k) Plan, you acknowledge
that spousal consent has been provided,
if required.
• Indemnify the trustee of the Fidelity
Retirement Plan and Trust Agreement and its
agents, affiliates, employees, and successors
from any liability associated with the distribu-
tions made at the direction of you and/or the
Plan Participant.
Customers requesting EFT:
• Authorize and request Fidelity to make EFT
distributions from the Fidelity Retirement
Plan accounts listed in this form by initiat-
ing debit entries to the account indicated
in this form.
• Authorize and request the bank named in
Section 6 to accept debit entries initiated
by Fidelity in such account and to debit the
same account without responsibility for the
appropriateness or for the existence of any
further authorization.
PRINT PLAN ADMINISTRATOR NAME
PLAN ADMINISTRATOR SIGNATURE
SIGN
X
DATE MM/DD/YYYY
DATE
X
8b. Plan Participant
• Authorize and request the trustee of
the Fidelity Retirement Plan, Fidelity
Management Trust Company and its agents,
affiliates, employees, or successor custodians
(Fidelity), to make the above withdrawal.
• Acknowledge that Fidelity Retirement Plan
withdrawals will be taxed as ordinary income,
and may be subject to a 10% early with-
drawal penalty if taken before age 59½.
• Agree that if you are over the applicable
RMD age, you accept full responsibility for
withdrawing the RMD required by section
401(a)(9) of the Internal Revenue Code.
• Indemnify the trustee of the Fidelity
Retirement Plan and Trust Agreement and its
agents, affiliates, employees, and successors
from any liability associated with the distribu-
tions made at the direction of you and/or the
Plan Administrator.
• Certify, if indicated above, that your spouse
beneficiary who is more than 10 years
younger than you, has been the sole ben-
eficiary for the entire calendar year, that the
statement is correct as to the account cov-
ered by this automatic withdrawal plan, and
that you are aware that he or she must be
the sole beneficiary on the account covered
by this plan for the entire calendar year to be
eligible to have that year’s RMD calculation
based on the Spousal Exception Table.
• Confirm, if you are not a U.S. person (includ-
ing a resident alien individual), you have
attached, or have on file with Fidelity, IRS
Form W-8 that includes your U.S. taxpayer
identification number in order to claim tax
treaty benefits, if applicable.
Customers requesting EFT:
• Authorize and request Fidelity to make EFT
distributions from the Fidelity Retirement
Plan account listed in this form by initiating
debit entries to the account indicated in
this form.
• Authorize us, upon receiving instructions
from you or as otherwise authorized by you,
to make payments from you and to you or
to your designee, by credit or debit entries
to the designated account at the financial
institution named in this form or the finan-
cial institution specified in your existing
instructions (the “Bank”). You authorize
the Bank to process such entries and to
credit or debit the designated account at
that Bank for such entries. You ratify such
instructions and agree that neither we nor
any mutual fund will be liable for any loss,
liability, cost, or expense for acting upon all
such instructions believed to be genuine if
we employ reasonable procedures to pre-
vent unauthorized transactions. You agree
that this authorization may only be revoked
by written notice to us in such time and
manner as to afford us and the Bank a
reasonable opportunity to act upon it.
• Understand that Fidelity may purge unused
EFT instructions from your account on a
periodic basis without notice to you.
• Understand that Fidelity may terminate the
EFT instructions from your account at any
time in its sole discretion.
For Connecticut Residents:
• Acknowledge that, as a resident of CT, your
distributions from retirement accounts are
subject to the highest marginal tax rate. If
you are exempt from state tax, you have the
option to elect out of state tax withholding.
Otherwise, penalties may apply. The penalty
for reporting false information is a fine of
not more than $5,000, imprisonment for not
more than five years, or both.
• Confirm that your state tax withholding
election is true, complete, and correct.
Signatures and Dates continue on next page.
A Medallion signature guarantee is required:
• if the withdrawals are going to a Fidelity account with no common owner.
• to request a per-payment amount greater than $100,000.
If the form is completed at a Fidelity Investor Center, the Medallion signature guarantee is not required. You can get a Medallion signature
guarantee from most banks, credit unions, and other financial institutions. A notary seal/stamp is NOT a Medallion signature guarantee.
PRINT PLAN PARTICIPANT NAME
MEDALLION SIGNATURE GUARANTEE
PLAN PARTICIPANT SIGNATURE
SIGN
X
DATE MM/DD/YYYY
DATE
X
8c. Spousal Consent for Plan Participant Distributions Sign this section in the presence of a notary public.
Spousal consent is not required for an RMD.
By signing below, you:
• Consent to the form of distribution selected
by your spouse herein.
• Understand that by signing this consent, you
are giving up the right to receive annuity
benefit payments that would otherwise be
payable to you.
PRINT SPOUSE NAME
SPOUSE SIGNATURE DATE MM/DD/YYYY
SIGN
X X
Important Note: CA Notaries are permitted to submit a separate page notary document. If used, it must identify the
document being notarized.
Notice to CA Residents: A Notary Public or other officer completing this certificate verifies only the identity of the
individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of
that document.
Certificate of Acknowledgement of Notary Public
Must be a U.S. Notary. Foreign notary or consular seals may NOT be substituted.
State of , in the County of , subscribed and sworn to before me by the
above-named individual who is personally known to me or who has produced as identification, that the
foregoing statements were true and accurate and made of his/her own free act and deed, on / / .
PRINT NOTARY NAME
NOTARY SEAL / STAMP
NOTARY SIGNATURE DATE MM/DD/YYYY
SIGN
X X
My commission expires / / .
1.749593.117 Page 6 of 6 015400606
8. Signatures and Dates, continued
On this form, “Fidelity” means Fidelity Brokerage Services LLC and its affiliates. Brokerage services are
provided by Fidelity Brokerage Services LLC, Member NYSE, SIPC. 454467.14.0 (02/20)
Did you sign the form? Send the ENTIRE form and any attachments
to Fidelity Investments. You will receive a Revised Account Profile
confirming your distribution instructions.
Questions? Go to Fidelity.com/rmd or call 800-343-3548.
Regular mail
Attn: Retirement Distributions
Fidelity Investments
PO Box 770001
Cincinnati, OH 45277-0035
Overnight mail
Attn: Retirement Distributions
Fidelity Investments
100 Crosby Parkway KC1B
Covington, KY 41015
State Tax Withholding — Retirement Plan 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 penal-
ties for insufficient withholding.
• The state tax withholding rate, if indicated, must be
provided as a whole number from 1% to 100% for any
one-time withdrawals, or from 1% to 99% for any auto-
matic withdrawals.
Withholding Options
State of residence State tax withholding options
AK, FL, HI, 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,*
NE, OK, PR,
†
VA, 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.
CA, DE, GA,
†
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.
CT, MI
• CT and MI generally require state income tax of at least your state’s minimum requirements regardless of
whether or not federal income tax is withheld.
• Tax withholding is not required if you meet certain state requirements governing pension and retirement
benefits. Please reference the CT or MI W-4P Form for additional information about calculating the amount
to withhold from your distribution.
• If you are subject to state tax withholding, you must elect state tax withholding of at least your state’s mini-
mum by completing the Tax Withholding section.
•
Contact your tax advisor or investment representative for additional information about your state’s requirements.
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 minimum 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 minimum 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 nondeductible
contributions were made and you have no pretax earnings), you may be eligible to elect any of the
withholding options.
• If you wish to take a distribution of both taxable and nontaxable amounts, you must complete a separate
distribution request form for each and complete the Tax Withholding section of the forms, as appropriate.
ME,
†
MS
• 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.
OH
• State tax withholding is voluntary. If you choose state withholding, you can choose a higher rate than your
state’s minimum but not a lower rate.
SC
• SC requires state withholding if you have not provided a Tax ID or if you have been notified of a name/
Tax ID mismatch and have not resolved the issue. Otherwise, state tax withholding is voluntary and you can
choose the rate you want.
All other states
(and DC if not taking a
full distribution)
• State tax withholding is voluntary and you can choose the rate you want.
*When taking a single distribution
†
When taking periodic distributions
Important: State tax withholding rules can
change, and the rules cited above may
not reflect the current ruling of your state.
Consult with your tax advisor or state taxing
authority to obtain the most up-to-date
information pertaining to your state.
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.
Fidelity Brokerage Services LLC, Member NYSE, SIPC; National Financial Services LLC, Member NYSE, SIPC 671710.5.0 (02/19)
Page 1 of 1
1.9585653.104
Page 1 of 4
Notice Regarding Retirement Plan Payments —
Your Rollover Options
You are receiving this notice because all or a portion of a payment you are receiving from the___________________________[INSERT
NAME OF PLAN] (the “Plan”) is eligible to be rolled over to an IRA or an employer plan. This notice is intended to help you decide
whether to do such a rollover.
This notice describes the rollover rules that apply to payments from the Plan that are not from a designated Roth account (a type of
account with special tax rules in some employer plans). If you also receive a payment from a designated Roth account in the Plan,
you will be provided a different notice for that payment, and the Plan administrator or the payor will tell you the amount that is
being paid from each account.
Rules that apply to most payments from a plan are described in the “General Information About Rollovers” section. Special rules
that only apply in certain circumstances are described in the “Special Rules and Options” section.
GENERAL INFORMATION ABOUT ROLLOVERS
How can a rollover affect my taxes?
You will be taxed on a payment from the Plan if you do not
roll it over. If you are under age 59½ and do not do a roll-
over, you will also have to pay a 10% additional income tax
on early distributions (generally, distributions made before
age 59½), unless an exception applies. However, if you
do a rollover, you will not have to pay tax until you receive
payments later and the 10% additional income tax will not
apply if those payments are made after you are age 59½ (or if
an exception applies).
What types of retirement accounts and plans may
accept my rollover?
You may roll over the payment to either an IRA (an individual
retirement account or individual retirement annuity) or an
employer plan (a tax-qualified plan, section 403(b) plan, or
governmental section 457(b) plan) that will accept the rollover.
The rules of the IRA or employer plan that holds the rollover
will determine your investment options, fees, and rights to
payment from the IRA or employer plan (for example, no
spousal consent rules apply to IRAs and IRAs may not provide
loans). Further, the amount rolled over will become subject to
the tax rules that apply to the IRA or employer plan.
How do I do a rollover?
There are two ways to do a rollover. You can do either a
direct rollover or a 60-day rollover.
If you do a direct rollover, the Plan will make the payment
directly to your IRA or an employer plan. You should contact
the IRA sponsor or the administrator of the employer plan for
information on how to do a direct rollover.
If you do not do a direct rollover, you may still do a rollover
by making a deposit into an IRA or eligible employer plan
that will accept it. Generally, you will have 60 days after you
receive the payment to make the deposit. If you do not do
a direct rollover, the Plan is required to withhold 20% of the
taxable payment for federal income taxes (up to the amount
of cash and property received other than employer stock).
This means that, in order to roll over the entire payment
in a 60-day rollover, you must use other funds to make
up for the 20% withheld. If you do not roll over the entire
amount of the payment, the portion not rolled over will be
taxed and will be subject to the 10% additional income tax
on early distributions if you are under age 59½ (unless an
exception applies).
How much may I roll over?
If you wish to do a rollover, you may roll over all or part of
the amount eligible for rollover. Any payment from the Plan
is eligible for rollover, except:
• Certain payments spread over a period of at least 10 years
or over your life or life expectancy (or the lives or joint life
expectancy of you and your beneficiary);
• Required minimum distributions after age 70½ (if you were
born before July 1, 1949) or age 72 (if you were born after
June 30, 1949).
• Hardship distributions;
• ESOP dividends;
• Corrective distributions of contributions that exceed tax law
limitations;
• Loans treated as deemed distributions (for example, loans
in default due to missed payments before your employment
ends);
• Cost of life insurance paid by the Plan;
• Payments of certain automatic enrollment contributions
requested to be withdrawn within 90 days of the first
contribution; and
• Amounts treated as distributed because of a prohibited
allocation of S corporation stock under an ESOP (also, there
will generally be adverse tax consequences if you roll over a
distribution of S corporation stock to an IRA).
• Qualified birth or adoption distributions from an eligible
retirement plan or IRA. However, any such distribution may
be repaid as a rollover contribution to an eligible retirement
plan or IRA.
The Plan administrator or the payor can tell you what portion
of a payment is eligible for rollover.
1.820513.108
If I don’t do a rollover, will I have to pay the 10%
additional income tax on early distributions?
If you are under age 59½, you will have to pay the 10%
additional income tax on early distributions for any payment
from the Plan (including amounts withheld for income tax)
that you do not roll over, unless one of the exceptions listed
below applies. This tax applies to the part of the distribution
that you must include in income and is in addition to the
regular income tax on the payment not rolled over.
The 10% additional income tax does not apply to the
following payments from the Plan:
• Payments made after you separate from service if you will
be at least age 55 in the year of the separation;
• Payments from a pension, profit sharing, or 401(k) plan after
you attain age 59 1/2;
• Payments that start after you separate from service if
paid at least annually in equal or close to equal amounts
over your life or life expectancy (or the lives or joint life
expectancy of you and your beneficiary);
• Payments from a governmental plan made after you separate
from service if you are a qualified public safety employee and
you will be at least age 50 in the year of separation;
• Payments made due to disability;
• Payments after your death;
• Payments of ESOP dividends;
• Corrective distributions of contributions that exceed tax
law limitations;
• Cost of life insurance paid by the Plan;
• Payments made directly to the government to satisfy a
federal tax levy;
• Payments made under a qualified domestic relations
order (QDRO);
• Payments up to the amount of your deductible medical
expenses (without regard to whether you itemize
deductions for the taxable year);
• Certain payments made while you are on active duty if you
were a member of a reserve component called to duty after
September 11, 2001, for more than 179 days;
• Payments of certain automatic enrollment contributions
requested to be withdrawn within 90 days of the
first contribution;
• Payments due to major disasters that are located in a
qualified disaster area as declared by the President of the
United States under section 401 of the Robert T. Stafford
Disaster Relief and Emergency Assistance Act;
• Phased retirement payments made to federal employees;
and
• Qualified birth or adoption distributions from an eligible
retirement plan or IRA up to $5000 (in aggregate) per birth
or adoption.
If I do a rollover to an IRA, will the 10% additional
income tax apply to early distributions from
the IRA?
If you receive a payment from an IRA when you are under
age 59½, you will have to pay the 10% additional income
tax on early distributions on the part of the distribution that
you must include in income, unless an exception applies.
In general, the exceptions to the 10% additional income
tax for early distributions from an IRA are the same as the
exceptions listed above for early distributions from a plan.
However, there are a few differences for payments from an
IRA, including:
• The exception for payments made after you separate
from service if you will be at least age 55 in the year of the
separation (or age 50 for qualified public safety employees)
does not apply.
• The exception for qualified domestic relations orders
(QDROs) does not apply (although a special rule applies
under which, as part of a divorce or separation agreement,
a tax-free transfer may be made directly to an IRA of a
spouse or former spouse).
• The exception for payments made at least annually in equal
or close to equal amounts over a specified period applies
without regard to whether you have had a separation
from service.
• There are additional exceptions for (1) payments for
qualified higher education expenses, (2) payments up
to $10,000 used in a qualified first-time home purchase,
and (3) payments for health insurance premiums after
you have received unemployment compensation for 12
consecutive weeks (or would have been eligible to receive
unemployment compensation but for self-employed status).
Will I owe State income taxes?
This notice does not describe any State or local income tax
rules (including withholding rules).
SPECIAL RULES AND OPTIONS
If your payment includes after-tax contributions
After-tax contributions included in a payment are not taxed.
If a payment is only part of your benefit, an allocable portion
of your after-tax contributions is included in the payment, so
you cannot take a payment of only after-tax contributions.
However, if you have pre-1987 after-tax contributions
maintained in a separate account, a special rule may apply to
determine whether the after-tax contributions are included
in a payment. In addition, special rules apply when you do a
rollover, as described below.
You may roll over to an IRA a payment that includes after-
tax contributions through either a direct rollover or a 60-day
rollover. You must keep track of the aggregate amount of
the after-tax contributions in all of your IRAs (in order to
determine your taxable income for later payments from
Page 2 of 4
1.820513.108
Page 3 of 41.820513.108
the IRAs). If you do a direct rollover of only a portion of the
amount paid from the Plan and at the same time the rest
is paid to you, the portion directly rolled over consists first
of the amount that would be taxable if not rolled over. For
example, assume you are receiving a distribution of $12,000,
of which $2,000 is after-tax contributions. In this case, if you
directly roll over $10,000 to an IRA that is not a Roth IRA, no
amount is taxable because the $2,000 amount not directly
rolled over is treated as being after-tax contributions. If you
do a direct rollover of the entire amount paid from the Plan to
two or more destinations at the same time, you can choose
which destination receives the after-tax contributions.
If you do a 60-day rollover to an IRA of only a portion of a
payment made to you, the after-tax contributions are treated
as rolled over last. For example, assume you are receiving
a distribution of $12,000, of which $2,000 is after-tax
contributions, and no part of the distribution is directly rolled
over. In this case, if you roll over $10,000 to an IRA that is not
a Roth IRA in a 60-day rollover, no amount is taxable because
the $2,000 amount not rolled over is treated as being after-
tax contributions.
You may roll over to an employer plan all of a payment that
includes after-tax contributions, but only through a direct
rollover (and only if the receiving plan separately accounts
for after-tax contributions and is not a governmental
section 457(b) plan). You can do a 60-day rollover to an
employer plan of part of a payment that includes after-tax
contributions, but only up to the amount of the payment that
would be taxable if not rolled over.
If you miss the 60-day rollover deadline
Generally, the 60-day rollover deadline cannot be extended.
However, the IRS has the limited authority to waive the dead-
line under certain extraordinary circumstances, such as when
external events prevented you from completing the rollover
by the 60-day rollover deadline. Under certain circumstances,
you may claim eligibility for a waiver of the 60-day rollover
deadline by making a written self-certification. Otherwise, to
apply for a waiver from the IRS, you must file a private letter
ruling request with the IRS. Private letter ruling requests
require the payment of a nonrefundable user fee. For more
information, see IRS Publication 590-A, Contributions to
Individual Retirement Arrangements (IRAs).
If your payment includes employer stock that you
do not roll over
If you do not do a rollover, you can apply a special rule to
payments of employer stock (or other employer securities)
that are either attributable to after-tax contributions or paid
in a lump sum after separation from service (or after age
59½, disability, or the participant’s death). Under the
special rule, the net unrealized appreciation on the stock
will not be taxed when distributed from the Plan and will
be taxed at capital gain rates when you sell the stock. Net
unrealized appreciation is generally the increase in the
value of employer stock after it was acquired by the Plan.
If you do a rollover for a payment that includes employer
stock (for example, by selling the stock and rolling over the
proceeds within 60 days of the payment), the special rule
relating to the distributed employer stock will not apply to
any subsequent payments from the IRA or employer plan.
The Plan administrator can tell you the amount of any net
unrealized appreciation.
If you were born on or before January 1, 1936
If you were born on or before January 1, 1936, and receive a
lump sum distribution that you do not roll over, special rules
for calculating the amount of the tax on the payment might
apply to you. For more information, see IRS Publication 575,
Pension and Annuity Income.
If you roll over your payment to a Roth IRA
If you roll over a payment from the Plan to a Roth IRA, a
special rule applies under which the amount of the payment
rolled over (reduced by any after-tax amounts) will be
taxed. However, the 10% additional income tax on early
distributions will not apply (unless you take the amount
rolled over out of the Roth IRA within 5 years, counting from
January 1 of the year of the rollover).
If you roll over the payment to a Roth IRA, later payments from
the Roth IRA that are qualified distributions will not be taxed
(including earnings after the rollover). A qualified distribution
from a Roth IRA is a payment made after you are age 59½
(or after your death or disability, or as a qualified first-time
homebuyer distribution of up to $10,000) and after you have had
a Roth IRA for at least 5 years. In applying this 5-year rule, you
count from January 1 of the year for which your first contribution
was made to a Roth IRA. Payments from the Roth IRA that are
not qualified distributions will be taxed to the extent of earnings
after the rollover, including the 10% additional income tax on
early distributions (unless an exception applies). You do not have
to take required mini-mum distributions from a Roth IRA during
your lifetime. For more information, see IRS Publication 590-A,
Contributions to Individual Retirement Arrangements (IRAs), and
IRS Publication 590-B, Distributions from Individual Retirement
Arrangements (IRAs).
If you are not a plan participant
Payments after death of the participant. If you receive a
distribution after the participant’s death that you do not roll
over, the distribution will generally be taxed in the same
manner described elsewhere in this notice. However, the 10%
additional income tax on early distributions and the special
rules for public safety officers do not apply, and the special
rule described under the section “If you were born on or
before January 1, 1936” applies only if the participant was
born on or before January 1, 1936.
If you are a surviving spouse. If you receive a payment
from the Plan as the surviving spouse of a deceased
participant, you have the same rollover options that the
participant would have had, as described elsewhere in this
notice. In addition, if you choose to do a rollover to an IRA,
you may treat the IRA as your own or as an inherited IRA.
Page 4 of 41.820513.108
An IRA you treat as your own is treated like any other IRA
of yours, so that payments made to you before you are
age 59½ will be subject to the 10% additional income tax
on early distributions (unless an exception applies) and
required minimum distributions from your IRA do not
have to start until after you are age 70½ (if you were born
before July 1, 1949) or age 72 (if you were born after
June 30, 1949).
If you treat the IRA as an inherited IRA, payments from the
IRA will not be subject to the 10% additional income tax on
early distributions. However, if the participant had started
taking required minimum distributions, you will have to
receive required minimum distributions from the inherited
IRA. If the participant had not started taking required
minimum distributions from the Plan, you will not have to start
receiving required minimum distributions from the inherited
IRA until the year the participant would have been age 70½
(if he or she was born before July 1, 1949) or age 72 (if he or
she was born after June 30, 1949).
If you are a surviving beneficiary other than a spouse. If you
receive a payment from the Plan because of the participant’s
death and you are a designated beneficiary other than a
surviving spouse, the only rollover option you have is to do a
direct rollover to an inherited IRA. Payments from the inherited
IRA will not be subject to the 10% additional income tax on
early distributions. You will have to receive required minimum
distributions from the inherited IRA.
Payments under a qualified domestic relations order. If you
are the spouse or former spouse of the participant who
receives a payment from the Plan under a qualified domestic
relations order (QDRO), you generally have the same options
and the same tax treatment that the participant would have
(for example, you may roll over the payment to your own IRA
or an eligible employer plan that will accept it). However,
payments under the QDRO will not be subject to the 10%
additional income tax on early distributions.
If you are a nonresident alien
If you are a nonresident alien and you do not do a direct rollover
to a U.S. IRA or U.S. employer plan, instead of withholding 20%
of the taxable amount, the Plan is generally required to withhold
30% of the taxable amount of the payment for federal income
taxes. If the amount withheld exceeds the amount of tax you owe
(as may happen if you do a 60-day rollover), you may request
an income tax refund by filing Form 1040NR and attaching
your Form 1042-S. See Form W-8BEN for claiming that you are
entitled to a reduced rate of withholding under an income tax
treaty. For more information, see also IRS Publication 519, U.S.
Tax Guide for Aliens, and IRS Publication 515, Withholding of Tax
on Nonresident Aliens and Foreign Entities.
Other special rules
If a payment is one in a series of payments for less than 10
years, your choice whether to make a direct rollover will apply
to all later payments in the series (unless you make a different
choice for later payments).
If your payments for the year are less than $200 (not including
payments from a designated Roth account in the Plan), the
Plan is not required to allow you to do a direct rollover and is
not required to withhold for federal income taxes. However,
you may do a 60-day rollover.
Unless you elect otherwise, a mandatory cashout of more
than $1,000 (not including payments from a designated Roth
account in the Plan) will be directly rolled over to an IRA
chosen by the Plan administrator or the payor. A mandatory
cashout is a payment from a plan to a participant made
before age 62 (or normal retirement age, if later) and without
consent, where the participant’s benefit does not exceed
$5,000 (not including any amounts held under the plan as a
result of a prior rollover made to the plan).
You may have special rollover rights if you recently served
in the U.S. Armed Forces. For more information on special
rollover rights related to the U.S. Armed Forces, see IRS
Publication 3, Armed Forces’ Tax Guide. You also may have
special rollover rights if you were affected by a federally
declared disaster (or similar event), or if you received a
distribution on account of a disaster. For more information
on special rollover rights related to disaster relief, see the IRS
website at www.irs.gov.
FOR MORE INFORMATION
You may wish to consult with the Plan administrator or payor,
or a professional tax advisor, before taking a payment from
the Plan. Also, you can find more detailed information on
the federal tax treatment of payments from employer plans
in: IRS Publication 575, Pension and Annuity Income; IRS
Publication 590-A, Contributions to Individual Retirement
Arrangements (IRAs); IRS Publication 590-B, Distributions
from Individual Retirement Arrangements (IRAs); and IRS
Publication 571, Tax-Sheltered Annuity Plans (403(b) Plans).
These publications are available from a local IRS office, on
the web at www.irs.gov, or by calling 1-800-TAX-FORM.
Accounts carried by Fidelity Brokerage Services LLC and National Financial Services LLC, Members NYSE, SIPC.
1.820513.108 — 452034.7.0 (02/20)
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