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Page 1 of 6
Questions? Go to Fidelity.com/movemoney or call 800-343-3548.
One-Time Withdrawal — Fidelity Retirement Plan
Use this form to request a one-time withdrawal from a Fidelity Self-Employed 401(k), Profit Sharing, or Money Purchase Plan
account. Possible requests include a one-time, immediate distribution; a qualified or direct conversion to a Roth IRA; or a direct
rollover. 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, make a copy of the relevant page.
Helpful to Know
• Distributions from the Fidelity Retirement Plan [i.e., Profit
Sharing, Money Purchase Pension Plan, or Self-Employed
401(k) Plan] are only permitted when a participant
reaches age 59½, separates from service, becomes
disabled, the plan is terminated, or due to the death of
the participant. Distributions for any other reason may
result in plan disqualification.
• 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 con-
sent on this form. You are encouraged to consult your
tax advisor regarding the tax implications associated with
each distribution.
• Nonresident aliens must provide IRS Form W-8BEN and a
U.S. or foreign tax identification number.
• If you are making withdrawals from both a money
purchase plan and a profit-sharing plan, you must
complete a separate form for each account.
• 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.
• 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.
1. Account Owner
Name Fidelity Account Number
Social Security or Taxpayer ID Number Date of Birth MM DD YYYY
Daytime Phone Extension
Plan Information
Plan Name
Money Purchase Spousal consent and notary required.
Profit Sharing [including Self-Employed 401(k)]
2. Request Reason
Normal You are AT LEAST 59½ at the time of distribution.
Separated from service
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.
Death of plan participant
Plan termination
This phone number
may be used if we have
questions, but will not
be used to update your
account information.
Check ONLY one.
1.812111.116 015220801
Request Reason continues on next page.
Print
Reset
Save
Page 2 of 61.812111.116 015220802
Required Minimum Distribution (RMD)
Check here if you are required to take an RMD and are requesting to do so with this form. Please note that IRS rules pro-
hibit your RMD from being rolled over/converted; by checking this box, you are directing Fidelity to distribute your RMD
as a separate payment from the rollover/conversion. You will be able to choose the method of payment(s) in Section 4.
Amount
$
.
3. 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
be closed.
• Once we receive this form in good
order, you cannot cancel your
distribution request.
Cash Distributions from a Brokerage Retirement Plan 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 brokerage account.
Skip to Section 4.
ONLY the following amount of cash in your brokerage account:
Dollar Amount
Skip to Section 4.
$
All Other Types of Distributions
Trades may take up to five business days to process once determined to be in good order. Certain securities may not be eligible to sell
via this form. Examples of ineligible securities include options, certain fixed income securities, and thinly traded securities. To avoid any
possible delays, consider liquidating the positions either online or through a Fidelity representative prior to submitting this form.
In the event that transactions cannot be processed within five business days of determining your request to be in good order,
Fidelity will notify you and you may have to resubmit your request on the unsold positions within your account.
ENTIRE VALUE of your account in cash (all eligible securities will be sold)
ENTIRE VALUE of your account as shares (in kind) You must choose to distribute to a Fidelity account in
Section 4.
ONLY the following eligible securities and amounts:
Sell and distribute as cash
Distribute as shares (in kind)
Security Name or Symbol
ALL
shares
ONLY this
many shares:
Number of Shares
ONLY this
dollar amount:
Fidelity Mutual Fund
accounts only
.
Dollar Amount
$
Sell and distribute as cash
Distribute as shares (in kind)
Security Name or Symbol
ALL
shares
ONLY this
many shares:
Number of Shares
ONLY this
dollar amount:
Fidelity Mutual Fund
accounts only.
Dollar Amount
$
Provide the RMD
amount to be dis-
tributed. If the box
is checked and no
amount is provided,
Fidelity will calculate
your RMD amount.
If the amount you
indicate is greater
than your core
account balance,
your request will
be denied.
2. Request Reason, continued
Form continues on next page.
1.812111.116 Page 3 of 6 015220803
4. Distribution Method
You must obtain a Medallion signature guarantee in Section 6b if requesting bank wire, if sending a distribution to a payee other than the
Fidelity Retirement Plan account owner or alternate address, if the address on the account has been changed within the past 10 days, or for
any transaction over $100,000.
4a. Distribute into your Fidelity nonretirement account
Fidelity Nonretirement Account Number Fidelity Fund Name or Symbol Fidelity Mutual Fund accounts ONLY e.g., 2AB-123456
4b. Direct rollover/conversion of an eligible distribution into an account held with Fidelity. Please note that while
rollovers are generally non-taxable transactions, conversions to a Roth IRA are generally taxable as income
in the year of the conversion. The Tax Cuts and Jobs Act eliminated the ability to recharacterize any conversions
made in 2018 or after, so you may want to consult a tax professional prior to requesting a conversion.
Fidelity Account Number Fidelity Fund Name or Symbol Fidelity Mutual Fund accounts ONLY e.g., 2AB-123456
Direct rollover to a Fidelity Traditional IRA or Fidelity Rollover IRA
Direct conversion to a Fidelity Roth IRA
Direct rollover to a Fidelity Inherited IRA Decedent must be the same on both accounts.
4c. Direct rollover/conversion of an eligible distribution into an established non-Fidelity account. Please note
that while rollovers are generally non-taxable transactions, conversions to a Roth IRA are generally taxable as
income in the year of the conversion. The Tax Cuts and Jobs Act eliminated the ability to recharacterize any con-
versions made in 2018 or after, so you may want to consult a tax professional prior to requesting a conversion.
Direct rollover to a non-Fidelity Traditional IRA or Rollover IRA
Direct conversion to a non-Fidelity Roth IRA
Direct rollover to a non-Fidelity Inherited IRA The decedent must be the same.
Trustee/Custodian Name Account Number
For Benefit Of/Attention Address
City State/Province ZIP/Postal Code Country
4d. Bank wire to a bank or credit union account or someone else’s (cash only): Ask the bank for its wire routing
number. The bank may charge a fee for wire transfers.
Wire Recipient
Bank Routing /ABA Number Bank Name
Account Number Account Owner Name(s) Required
Address of Wire Recipient
City State/Province ZIP/Postal Code Country
For Further Credit
Additional Details (if applicable)
Instructions to be included with the wire transfer.
Check the appropriate
method(s) and provide
all required informa-
tion. If you indicated
in Section 2 that you
are requesting your
RMD, choose method
4a, 4d, 4e, or 4f. If you
would also like to roll
over/convert any of
the remaining balance,
choose from method
4b or 4c.
All bank wire requests
MUST have a Medallion
signature guarantee. A
notary seal/stamp is
NOT a Medallion
signature guarantee.
FULL address is
required for
international wires.
Distribution Method continues on next page.
1.812111.116 Page 4 of 6 015220804
Correspondent (Intermediary)
Correspondent Bank Routing/ABA Number Correspondent Bank Name
Account is OUTSIDE the United States:
SWIFT Code Name of Country
4e. Check mailed to the address of record
Default if no choice indicated or if we are unable to process your choice.
4f. Check mailed to you at an address other than your record address
Address
City State ZIP Code
5. Tax Withholding
NOTE: If your distribution is eligible for a rollover/conversion and that is the only payment method chosen in Section 4, tax withholding
is not mandated by the IRS and cannot be withheld on this request. Please skip to Section 6.
Do NOT complete this section if you are a nonresident alien. Instead, the nonresident alien tax-withholding rate of 30% will apply.
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 one-time withdrawals that are not subject to the 20% withholding as described above, such as RMDs, IRS regulations require federal tax
withholding at the rate of 10%, unless you elect not to have withholding apply. If federal income tax withholding is applied to your distribu-
tion, state income tax may also apply. See “State Tax Withholding — Retirement Plan Withdrawals” at the end of this form.
Specify your tax withholding election. Only applicable if not subject to mandatory withholding.
Federal
Do NOT withhold federal taxes
Withhold federal taxes at the rate of:
Percentage
Minimum 10%. Whole numbers; no dollar
amounts. Note that 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
Whole numbers; no dollar amounts.
%
6. Signatures and Dates Plan Administrator and Plan Participant must sign and date.
Who must sign?
The Plan Administrator must sign in 6a.
The Plan Participant must sign in 6b.
If the distribution is due to death from your inherited retirement plan account:
– The executor of the Plan Administrator’s estate must sign in 6a.
– The inherited account owner must sign in 6b.
– No spousal beneficiary signature is required. Note: Spousal consent to the designation of a nonspouse beneficiary is required.
If you are married, your spouse must consent to this distribution by signing in the presence of a notary public in 6c. if:
– You are a participant in a profit sharing plan and elect to have your distribution paid in the form of a life annuity contract;
– You are a participant in a money purchase pension plan and elect a form of distribution other than a joint and survivor annuity, or you
are a participant in a profit sharing plan consisting of assets that have been transferred from a plan previously subject to the spousal
consent rules, such as a money purchase pension plan, and elect a form of distribution other than a joint and survivor annuity.
Spousal consent is not required for an RMD.
Important note: A participant may waive a qualified joint and survivor annuity option, and a spouse may consent to such waiver, provided it
is made within 90 days before the first plan distribution.
If the bank uses a corre-
spondent bank, provide
the information here.
Correspondent bank
information may not be
required for all wires.
Indicate if the recipient
bank is outside the
United States.
Check one in
each column.
Account owner’s
legal/residential
address determines
which state’s tax
rules apply.
4. Distribution Method, continued
Signatures and Dates continues on next page.
Indicate the plan participant’s marital status:
Single Married
By signing below, you:
• Certify that this designation is being made
pursuant to the Fidelity Retirement Plan and
Trust Agreement and the instructions con-
tained herein.
• Authorize and request the trustee of
the Fidelity Retirement Plan, Fidelity
Management Trust Company, or its agents,
affiliates, employees, or successors, to make
the above withdrawal.
• Agree that the participant, if over age 70½,
accepts 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, its
agents, affiliates, employees, and successors
from any liability associated with the
distributions made at the direction of you
and/or the Plan Administrator.
• Authorize and request National Financial
Services LLC (NFS) and/or Fidelity Brokerage
Services LLC (FBS) to make distributions
according to the above instructions. If you
have indicated herein that such payments
are to be credited to your bank account, you
authorize the bank or credit union maintain-
ing the account indicated above to accept
any such credit entries initiated by NFS or
FBS to such account and to credit the same
to such account, without responsibility for the
correctness thereof or for the existence of any
further authorization relating hereto.
• Certify that the trust is a qualifying nonspouse
beneficiary, for the purpose of section
402(c) of the Internal Revenue Code, and is
therefore eligible to directly roll over assets
to an inherited IRA, to the extent that assets
inherited by a trust are being directly rolled
over to an inherited IRA, as trustee for the
above-referenced trust.
• Understand that it is your responsibility to
ensure that only eligible assets are rolled over
and all minimum distribution requirements
are satisfied, to the extent that plan assets are
being directly rolled over to an IRA or inher-
ited IRA or directly converted to a Roth IRA.
•
Confirm, if you are not a U.S. person, you
have attached, or have on file with Fidelity,
IRS Form W-8BEN that includes your U.S. or
foreign tax identification number.
Customers requesting trade processing:
• Authorize Fidelity to process trades on
your behalf.
• Acknowledge that you are delegating to
Fidelity the discretion to determine the price
and time at which certain securities should be
sold pursuant to your instructions contained in
this form.
• Acknowledge that trades may take up to five
business days to process once the request is
received and determined to be in good order,
and that your authorization shall remain in
effect during the entire period.
• Acknowledge that certain securities cannot be
sold through this form and may require you to
call a representative or go online to process
the trades.
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 with-
holding. Otherwise, penalties may apply.
The penalty for reporting false information
is a fine of not more than $5,000, imprison-
ment for not more than five years, or both.
• Confirm that your state tax withholding
election is true, complete, and correct.
6a. Plan Administrator or Executor of the Plan Administrator’s Estate
PRINT PLAN ADMINISTRATOR/EXECUTOR NAME
PLAN ADMINISTRATOR/EXECUTOR SIGNATURE DATE MM/DD/YYYY
SIGN
X X
6b. Plan Participant or Inherited Account Owner
A Medallion signature guarantee is required if requesting a bank wire, if sending a withdrawal to an alternate payee or address, if the address
on the account has been changed within the past 10 days, or for any transaction over $100,000. 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/INHERITED ACCOUNT OWNER NAME
MEDALLION SIGNATURE GUARANTEE
PLAN PARTICIPANT/INHERITED ACCOUNT OWNER SIGNATURE
SIGN
X
DATE MM/DD/YYYY
DATE
X
6. Signatures and Dates, continued
1.812111.116 Page 5 of 6 015220805
Signatures and Dates continues on next page.
1.812111.116 Page 6 of 6 015220806
On this form, “Fidelity” means Fidelity Brokerage Services LLC and its affiliates. Brokerage services are
provided by Fidelity Brokerage Services LLC, Member NYSE, SIPC. 454857.14.0 (10/19)
Did you sign the form? Send the ENTIRE form to
Fidelity Investments.
Questions? Go to Fidelity.com/movemoney 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
6c. Spousal Consent for Plan Participant Distributions Sign this section in the presence of a notary public.
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 / / .
6. Signatures and Dates, continued
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)
Questions? Go to Fidelity.com/security/overview or call 800-343-3548.
Let’s Talk about Protecting Your Money
A wire transfer is an easy, convenient way to send money to people you know. If you provide your information or send money to a scammer,
though, there is often little we can do to help get your money back. Here are some examples of common scams, things to ask yourself
before sending any funds, and what to do next if faced with one of these scams. Remember, in EVERY scenario, the first step is to STOP
communicating with the person immediately!
Romance Scam
What is it? A romance scam is a fraudulent scheme in which a fraudster pretends romantic interest in a target, establishes a relationship,
and then attempts to get money or personal sensitive information from the target under false pretenses.
What to do next if you suspect you’re a victim:
• Talk to someone you trust about your new relationship.
• Do a reverse image search of the person’s picture to see if it’s associated with another name or if the details don’t match.
Grandparent Scam
What is it? A scammer calls or emails you, posing as either a relative in distress or someone claiming to represent the relative (such as a
lawyer or law enforcement agent). The caller explains that the “relative” is in trouble and needs them to wire funds “immediately” for bail
money, lawyer’s fees, hospital bills, or another fictitious expense.
What to do next if you suspect you’re a victim:
• Call the relative (or their parent) directly, at their known phone number.
• If told you have to act quickly, resist that urge.
• Verify, verify, verify!
Sweepstakes/Inheritance Scam
What is it? You receive a notice stating that you’ve won a “big prize” or have received an unexpected inheritance. You’re told that in order
to claim the “prize” or “inheritance,” you need to send funds to cover “processing fees” or “taxes.” Once the money is sent, you never see
your prize or inheritance.
What to do next if you suspect you’re a victim:
• Independently verify the information by consulting reputable resources. Do not rely on resources the scammer gives you, since they are
probably involved in the scam as well.
• Remember, you cannot win a sweepstakes you never entered!
Investment Scam
What is it? An investment scam involves the illegal or purported sale of a financial instrument. The typical investment scam is characterized
by offers of low or no-risk investments, guaranteed returns, etc.
What to do next if you suspect you’re a victim:
• Don’t trust a person or company just because they have a website; a convincing website can be set up quickly.
• Be cautious when responding to special investment offers, especially through unsolicited email.
• Check with other resources regarding this person or company, and inquire about all the terms and conditions.
Watch for red flags Here are some examples of red flags that should make you think twice before sending money.
• A person or company solicits business from you rather than your finding them on your own.
• The requestor asks you to send the wire to a name different from their own.
• After just a few contacts, they profess strong feelings for you and ask to chat with you.
• They threaten legal action if the funds are not sent “right away.”
• The wiring instructions seem unusual, they change, or you’re asked to go to a different financial institution.
• You are coached on how to respond to questions your financial institution might ask you regarding the transaction.
• If you met on a dating site, they will try and move you away from the site and communicate via chat or email instead.
• Messages may be full of typing errors, poorly written, or vague, and may escalate quickly if you show resistance.
• The messages or calls become more desperate and/or persistent, and if you do send money, they ask you to send more.
Remember, if it seems too good to be true, it probably is!
Your security is our top priority. We’re here to help. If you have any concerns or want to know more about how to help protect yourself, talk to a
Fidelity representative or visit Fidelity’s Security Center online at Fidelity.com/security/overview. 928234.1.0 (05/20)
Page 1 of 11.9899061.100
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