Did you sign the form? Send the ENTIRE form
to Fidelity Investments.
Questions? Go to Fidelity.com/movemoney
or call 800-343-3548.
Attn: Retirement Distributions
PO Box 770001
Cincinnati, OH 45277-0035
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
• 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-
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
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
• 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
• 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