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1.908899.105
Questions? Go to Fidelity.com/rothira or call 800-343-3548.
006920501
Roth IRA Conversion
Use this form to request a conversion of all or any part of your Fidelity Traditional, Rollover, SEP, or SIMPLE IRA (“IRA”) to a Fidelity Roth IRA.
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, make a copy of the relevant page. If using a blank sheet, include the account numbers, your signature, and the date.
1. Account Information
Name Social Security or Taxpayer ID Number
From Fidelity IRA being converted
Account Number
To Fidelity Roth IRA
Account Number
Type of Fidelity IRA to be converted
Traditional IRA Rollover IRA SEP IRA
SIMPLE IRA Accounts held for less than two years may not be converted. Inherited Traditional IRA Spouse only.
(to Inherited Roth IRA)
2. Conversion Instructions
Convert your existing IRA to your Roth IRA indicated in the Account Information section as specified below. Select either Full Conversion in kind
or provide partial conversion instructions.
You must have sufficient
cash in your core position
in a Fidelity brokerage
IRA. If a liquidating
trade is necessary, go
to Fidelity.com or call a
Fidelity representative.
Full Conversion in kind Convert the entire balance of your IRA to your Roth IRA. The conversion will be based on the existing
positions in your IRA on the date of the conversion; the IRA will be closed and any residual income on the existing positions will
also be converted.
Partial Conversion in cash Convert the following dollar amount from your IRA to your Roth IRA.
Amount
$
.
Conversion Instructions continue on next page.
Helpful to Know
• The receiving Roth IRA must already be established or this
form must accompany a new account application. Go to
Fidelity.com/rothira to establish an account online.
• If you are younger than age 59½, an early withdrawal
penalty may apply to any amount distributed from your
IRA and not converted to a Roth IRA within 60 days.
• You are responsible for maintaining records of your Roth
IRA conversions, recharacterizations, and annual contribu-
tions in order to properly complete your federal tax return.
• If you use Automatic Investments, you are responsible for
making applicable changes to this feature.
• All open Good ‘Til Canceled (GTC) orders should be
canceled prior to submitting this request. If a request is
received that requires converting a position with an
open order, the order will be canceled. It will be your
responsibility to replace the order on the Roth IRA
account, if applicable.
• Important to Note: The Tax Cuts and Jobs Act eliminated
the ability to recharacterize any conversions made to a Roth
IRA in 2018 or after. You should consult a tax professional
prior to requesting a conversion, as any taxable amounts
converted will be subject to federal income taxes in the year
in which the conversion occurs.
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006920502
List the investments to
be converted in kind and
indicate the amount,
number of shares,
or check “All.”
Note: Amount can only
be used for Fidelity
Mutual Fund accounts
(ex. 2AB-XXXXXX.)
Partial Conversion in kind Convert the following positions from your IRA to your Roth IRA.
Investment Name/CUSIP/Symbol Amount Fidelity Mutual Fund IRA only
OR
OR
OR
Number of Shares/ALL
$
All
.
.
Investment Name/CUSIP/Symbol Amount Fidelity Mutual Fund IRA only Number of Shares/ALL
$
All
.
.
Investment Name/CUSIP/Symbol Amount Fidelity Mutual Fund IRA only Number of Shares/ALL
$
All
.
.
Investment Name/CUSIP/Symbol Amount Fidelity Mutual Fund IRA only
OR
OR
OR
Number of Shares/ALL
$
All
.
.
Investment Name/CUSIP/Symbol Amount Fidelity Mutual Fund IRA only Number of Shares/ALL
$
All
.
.
Investment Name/CUSIP/Symbol Amount Fidelity Mutual Fund IRA only Number of Shares/ALL
$
All
.
.
Optional.
Additional instructions attached. To list more securities, attach a separate sheet and include the account numbers for the IRA being
converted and the Roth IRA, and the names, CUSIPs, and amounts for each security. You must sign and date the attached instructions.
3. 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 (federal and state
tax withholding combined cannot total more than 99%). If you made nondeductible contributions to your IRA, this may result in excess with-
holding 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.
Federal
Do NOT withhold federal taxes
Withhold federal taxes at the rate of:
Percentage
Minimum 10%; maximum 99%. 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
Maximum 99%. Whole numbers;
no dollar amounts.
%
Check one in each
column. IRA owner’s
legal/residential
address determines
which state’s tax
rules apply.
2. Conversion Instructions, continued
Form continues on next page.
0069205031.908899.105
4. Signature and Date Form cannot be processed without signature and date.
By signing this form, you:
• Authorize and request the custodian for
the Fidelity IRA, Fidelity Management
Trust Company and its agents, affiliates,
employees, or successor custodians (Fidelity)
to make the above requested distribution
from your Fidelity IRA and conversion
contribution to your Fidelity Roth IRA.
• Indemnify Fidelity from any liability in
the event that you fail to meet any IRS
requirement.
• Understand that, for full conversions, any
Good ‘Til Canceled (GTC) orders for the
Fidelity IRA are canceled.
• Accept full responsibility for complying with
all IRS rules on conversions.
• Understand that the taxable converted
amount will be subject to federal income
taxes in the year in which the conversion
occurs.
• Affirm that, if you are required to take a
Required Minimum Distribution, you have
done so for the current year pursuant to
Section 401(a)(9) of the Internal Revenue
Code with respect to your Fidelity IRA
prior to this conversion, and you accept
full responsibility for complying with
these requirements.
• Certify under penalties of perjury that you
are a U.S. citizen or other U.S. person and
that the taxpayer identification number
shown on this form is your correct tax
identification number.
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.
PRINT OWNER NAME
OWNER SIGNATURE DATE MM/DD/YYYY
SIGN
X X
On this form, “Fidelity” means Fidelity Brokerage Services LLC and its affiliates. Brokerage services are
provided by Fidelity Brokerage Services LLC, Member NYSE, SIPC. 465360.11.0 (10/19)
Did you sign the form? Send the ENTIRE form to
Fidelity Investments.
Questions? Go to Fidelity.com/rothira or
call 800-343-3548.
Regular mail
Attn: Retirement Distributions
Fidelity Investments
PO Box 770001
Cincinnati, OH 45277-0044
Overnight mail
Attn: Retirement Distributions
Fidelity Investments
100 Crosby Parkway KC1B
Covington, KY 41015
Page 3 of 3
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
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Completed 15 July 2021

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