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Page 1 of 4
Questions? Go to Fidelity.com/movemoney or call 800-343-3548.
One-Time Withdrawal – IRA
Use this form to make a one-time, tax-reportable distribution from a Traditional, Rollover, Roth, SEP, SIMPLE, or Inherited IRA.
Do NOT use this form for Fidelity Retirement Plan accounts, annuities, nonretirement accounts, or for any IRA-to-IRA transfer.
Also, do NOT use this form to purchase an investment in your IRA. Go to Fidelity.com/forms to find the appropriate form. 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
• It is your responsibility to ensure that your IRA distributions
comply with IRS rules. All transactions made using this form
are reported to the IRS as an IRA distribution. You may want
to consult a tax advisor as such distribution generally results
in taxable income to you.
• Nonresident aliens must provide IRS form W-8BEN and a U.S.
or foreign tax identification number.
• If you are making withdrawals from more than one IRA, 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.
• 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.
•
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.
• If you are rolling over these assets to an employer plan, you may
be responsible for obtaining your Plan Administrator’s consent.
1. Account Owner
Name Fidelity IRA Number
Social Security or Taxpayer ID Number Daytime Phone Extension
2. Request Reason
Normal You are AT LEAST 59½ at the time of distribution.
Early distribution You are younger than 59½ at the time of distribution. An IRS early distribution penalty may apply.
Note: A distribution from a Roth IRA will be reported as an early distribution.
Death of original IRA owner For inherited accounts only.
Direct rollover to a workplace retirement plan, such as a 401(k):
Plan Name
3. Distribution Amount
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 IRA
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.
$
Phone number may
be used if we have
questions, but will not
be used to update your
account information.
Check ONLY one.
If directing your distri-
bution to an HSA as
a qualified HSA fund-
ing distribution, check
either “Normal” or
“Early distribution,“
as appropriate.
If the amount you
indicate is greater
than your core
account balance,
your request will
be denied.
1.932150.110 006890901
Distribution Amount continues on next page.
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Page 2 of 41.932150.110 006890902
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 into 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
$
4. Distribution Method
You must obtain a Medallion signature guarantee in Section 6 if requesting a bank wire, if sending a check to a payee other than the IRA
owner or alternate address, if the requested payment amount or direct rollover to a workplace retirement plan is over $100,000, or if the
address on the account has been changed within the past 10 days.
Direct rollover to a workplace retirement plan, check paid to a payee other than the IRA owner, or check
mailed to an alternate address:
Workplace Retirement Plan or Other Payee Name
Workplace Retirement Plan Account Number For Benefit Of/Attention
Address
City State/Province ZIP/Postal Code Country
Electronic funds transfer (EFT) to a bank or credit union account using EFT instructions already in place on the
account (cash only). This form cannot be used to set up EFT. To add EFT to an account, go to Fidelity.com/eft or com-
plete the Electronic Funds Transfer (EFT) Authorization form.
A. EFT to your bank account. The names on the bank account and the IRA are the same.
B. EFT to someone else. (Available for brokerage accounts only.) The names on the bank account and the IRA
are different.
If EFT has not been established prior to the receipt of this request, a check will be mailed to the address
of record.
Bank Account Number
Distribute into a Fidelity nonretirement, investment-only retirement, Fidelity Retirement Plan account, or your
own Fidelity HSA: Requires Medallion signature guarantee if going to an account of which you are not an owner.
Fidelity Nonretirement or HSA Account Number Fidelity Fund Name or Symbol Mutual fund accounts ONLY
Check mailed to the address of record
Default if no choice indicated or if we are unable to process your choice.
Check one and
provide all required
information.
Provide bank informa-
tion ONLY if there are
multiple EFT instruc-
tions on the account
identified in Section 1.
3. Distribution Amount, continued
Distribution Method continues on next page.
1.932150.110 Page 3 of 4 006890903
Bank wire to a bank or credit union account in your name 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.
Correspondent (Intermediary)
Correspondent Bank Routing/ABA Number Correspondent Bank Name
Account is OUTSIDE the United States:
SWIFT Code Name of Country
5. Tax Withholding
Distributions from your non-Roth IRA are subject to federal and, where applicable, state income tax withholding unless you elect not to
have withholding apply below (if you are a U.S. citizen or other U.S. person). If you do not elect out of withholding, federal income tax
will be withheld at the rate of 10% from your total IRA distribution amount, unless you indicate a higher percentage below. If you made
nondeductible contributions to your IRA, this may result in excess withholding from your distributions. If you elect not to have withholding
apply to your distributions or if you do not have enough federal income tax withheld from your distribution, you may be responsible for
payment of estimated tax. You may incur penalties under the estimated tax rules if your withholding and estimated tax payments are not
sufficient. See “State Tax Withholding — IRA Withdrawals” at the end of this form.
Do NOT complete this section if you are a nonresident alien. Instead, the nonresident alien tax-withholding rate of 30% will apply.
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.
%
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.
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. IRA owner’s
legal/residential
address determines
which state’s tax
rules apply.
4. Distribution Method, continued
Form continues on next page.
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
Fidelity Investments
Attn: Retirement Distributions
PO Box 770001
Cincinnati, OH 45277-0035
Overnight mail
Fidelity Investments
Attn: Retirement Distributions
100 Crosby Parkway KC1B
Covington, KY 41015
On this form, “Fidelity” means Fidelity Brokerage Services LLC and its affiliates. Brokerage services are
provided by Fidelity Brokerage Services LLC, Member NYSE, SIPC. 592522.11.0 (10/19)
1.932150.110 Page 4 of 4 006890904
6. Signature and Date Account owner must sign and date.
By signing below, you:
• Authorize and request the custodian for
the Fidelity IRA, Fidelity Management
Trust Company and its agents, affiliates,
employees or successor custodians
(Fidelity) to withdraw the amount indicated
in Section 3 of this form.
• Acknowledge that non-Roth IRA distribu-
tions will generally be taxed as ordinary
income, and may be subject to a 10% early
withdrawal penalty if taken before age 59½.
• Acknowledge that distributions from a
Roth IRA that are attributable to earnings
may be taxed as ordinary income and may
be subject to a 10% early withdrawal pen-
alty unless certain conditions are met.
• Acknowledge that Fidelity is not respon-
sible for changes in the value of assets that
may occur during the distribution process.
• Acknowledge that distributions made from
any SIMPLE IRA prior to age 59½ and
within the first two years of participating
in an employer’s SIMPLE IRA plan may be
subject to a 25% penalty.
• Acknowledge that if taking Substantially
Equal Periodic Payments, it is your respon-
sibility to comply with the IRS rules, and
that Fidelity reports such distributions as
“Early Withdrawal — no known exception”
in accordance with IRS requirements.
• Indemnify Fidelity from any liability
in the event that you fail to meet any
IRS requirement.
• Confirm, if you are not a U.S. person,
that you have attached or have on file
with Fidelity IRS Form W-8BEN that
includes your U.S. or foreign tax identifica-
tion number.
Customers requesting EFT:
• Authorize and request Fidelity to make EFT
distributions from the Fidelity IRA listed in
this form by initiating debit entries to the
account indicated in this form.
• Authorize and request the bank named in
Section 4 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.
Customers transferring assets to an HSA:
• Acknowledge that qualified HSA funding
distributions are not subject to the 10%
early withdrawal penalty when transferred
directly to an HSA.
Customers transferring to a Fidelity Profit
Sharing or Self-Employed 401(k) Retirement
Plan account:
• Acknowledge that you have obtained
Plan Administrator consent to roll over the
amount listed on this form into your Fidelity
Retirement Plan account.
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 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.
A Medallion signature guarantee is required:
• to send a check to an alternate address or payee.
• to send a direct rollover to a workplace retirement plan AND the amount is greater than $100,000.
• to request a bank wire.
• if the address on the account has been changed within the past 10 days.
• if the withdrawal is going to a Fidelity account with no common owner.
• if the transaction is 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 OWNER NAME
MEDALLION SIGNATURE GUARANTEE
OWNER SIGNATURE
SIGN
X
DATE MM/DD/YYYY
DATE
X
State Tax Withholding — IRA 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.
• Withholding taxes for Roth IRA distributions is optional.
• 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,
OK, 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,
except on Roth IRA distributions.
CA, DE, 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,
except on Roth IRA distributions.
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
minimum 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 pre-tax 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.
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,
except on Roth IRA distributions.
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, except on Roth IRA distributions.
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.
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 652041.6.0 (02/19)
Page 1 of 1
1.964543.105
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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