Instructions Fidelity Investments Distribution Form

Instructions
Fidelity Investments Distribution Form
Before you complete a Fidelity Investments Distribution Form, please read the following instructions. Each item listed below corresponds
with the steps on the form and contains important information that you might want to consider before completing the form. If you need
more information please call a Fidelity Retirement Service Specialist at 1-800-343-0860 Monday through Friday from 8:00 A.M. to midnight ET.
It is not necessary to include the instructions when returning the distribution form.
STEP 1 PARTICIPANT INFORMATION
Address Change: Please be aware that if the address provided on the distribution form is different from the address on your statement, we will
change your address as indicated on the distribution form. No distributions from your account will be processed until 15 calendar days have elapsed
from the date of the address change unless you provide a signature guarantee (see step 8). All correspondence for your account will then be sent to
the new address.
STEP 2 REASON FOR DISTRIBUTION
You must indicate a reason for distribution. Federal tax law and your retirement plan allow distributions only for certain events. Please note the
appropriate reason on the enclosed distribution form.
Disability: Under Internal Revenue Code Section 72(m)(7), an individual is deemed to be disabled if “he is unable to engage in any substantial
gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or to be of
long-continued and indefinite duration.” (The Social Security definition of disability does not apply here). Proof of disability may be required by
the IRS. The 10% early withdrawal penalty is not imposed on distributions taken due to disability that meets the IRS definition.
In-service withdrawal: In-Service withdrawals may not be available from some sources and/or funds. Check with your employer or Fidelity to determine the available sources and/or funds.
Financial Hardship: Your plan sponsor determines the allowable reasons for a financial hardship. Some of the possible reasons for a
financial hardship distribution that fall under the IRS Safe Harbor guidelines are
• purchase of a primary residence
• payment of certain unreimbursed medical bills
• prevention of eviction
• payment of post secondary education tuition
When requesting a financial hardship, depending on your plan, you generally must obtain the approval of your plan sponsor. The IRS
may assess the 10% early withdrawal penalty for a financial hardship distribution if you are under the age of 591/2. Please indicate
your reason for financial hardship on the line provided on the Distribution Form.
If you are taking a distribution for a financial hardship reason, please note you can not choose direct rollover, systematic withdrawal
plan, or an income annuity.
STEP 3 AMOUNT OF DISTRIBUTION
Check with your Plan Administrator to determine what distribution options are available under the terms of your Employer’s Plan.
Full Withdrawal: Select this option to liquidate your entire account balance.
Partial Withdrawal: If you choose to distribute money from a specific fund(s), please provide the five digit fund number. You can find
this on the Web at www.fidelity.com or by contacting a Retirement Service Specialist at the number listed above.
Systematic Withdrawal Plan: If you would like to receive your distribution in the form of periodic payments, please fill in the amount
you wish to receive and from which fund(s).
Specific Dollar Method: If you would like a specific amount sent to you on an installment basis, check the Specific Dollar Method and list
the amount you would like to receive each time. Please indicate the date you would like to begin receiving distributions and at what intervals
(monthly, quarterly, or annually). This method will continue until the full balance you have specified has been distributed. You may change or
discontinue this option at any time in writing. Please allow five business days to process any change.
Specific Period Method: If you would like to pay out your entire account balance over a period of time, check the Specific Period Method.
If you choose the SWP option, you do not need to complete STEP 4.
Fees may apply. See your prospectus or certificate for details. Please note that the applicable fees may lower your distribution amount.
STEP 4 METHOD OF DISTRIBUTION
Direct Rollover: Taxes will not be withheld if we make the check payable to another investment provider for your benefit (FBO).
After-tax: Unless you check the box “Exclude my after-tax money from the rollover and return it to me,” we will include all after-tax contributions as part of your rollover. If you choose to exclude the after-tax contributions from your rollover, two checks will be issued. The first check
will be made payable to the investment provider of your choice and sent to you for all pretax and after-tax earnings. The second check will be
made payable and sent to you and will include after-tax contributions only.Please note your after-tax contributions may not be accepted by
your new plan.
IRA: If you choose to roll this distribution to an IRA that contains money from other sources, you may forfeit the right
to roll over the value of this distribution to another retirement plan in the future.
If you choose to rollover your after-tax contributions, it is your responsibility to keep track of your after-tax contribution
amount. This is very important for future distributions from your IRA so that these funds will not be taxed again. If you
choose to roll this distribution to purchase an Income Annuity, please call 1-800-343-0860 Monday - Friday, 8:00 a.m to
midnight, ET, to request an application and additional information.
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STEP 5 INDICATE HOW YOU WOULD LIKE TO RECEIVE THE PAYMENTS
Choose only one option of how you would like to receive your distribution.
STEP 6 SPOUSAL CONSENT
If you are married and you do not specify a distribution in the form of a qualified joint and 50% (or a higher percentage, if so
provided under your Employer’s Plan) survivor annuity, then your spouse must sign the consent portion of this form in the
presence of a notary public or a representative of your Employer’s Plan. The spousal consent is valid until you change your
distribution election.
If you are single, please check the “Single” box and skip to STEP 7.
If you are married, please check the “Married” box and obtain notarized spousal consent which includes
• your spouse’s signature
• your notary’s signature
• your notary’s seal/stamp (based on his/her state requirements)
• the date your notary’s commission expires.
Your plan representative can sign in place of a notary only if your plan allows. Please check with a Fidelity Retirement Services Specialist
to see if your plan allows this option.
If your plan is not subject to the Qualified Joint and Survivor Annuity Rules, or you are specifying a qualified joint and survivor annuity as your
method of distribution, your spouse does not have to sign.
STEP 7 INCOME TAX WITHHOLDING
Eligible Rollover Distributions:
• Separation from service
• Disability
• Partial distributions
• Full distributions
• Attainment of age 59 1/2
• Specific period, if less than 10 years
Non- Eligible Rollover Distributions:
• Distributions which take place over a period of 10 or more years
• Financial hardships
Federal Income Taxes:
20% federal income tax will be withheld from your distribution if an eligible rollover distribution is not rolled over directly to another
employer sponsored retirement plan, or an IRA. The federal income tax withholding is mandatory if you elect one of the following
distribution options: total distribution, partial distribution, or specific period, if less than 10 years.
How to Elect More than Mandatory 20% Withholding for Federal Taxes
If you would like Fidelity Investments to withhold more than the mandatory 20% federal income tax, please specify in STEP 7
State Income Taxes:
Please note that some states require Fidelity Investments to withhold state income taxes. We are unable to withhold additional state taxes.
Financial Hardships:
Unless otherwise directed by you, we will automatically withhold 10% for federal income taxes. You may choose to elect out of federal income tax
withholding at the time of your hardship distribution. Please mark the box “I elect not to have federal income taxes withheld from my distribution.”
For more information about income tax withholding for distributions, please refer to IRS Form W-4P at www.irs.gov.
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STEP 8 YOUR SIGNATURE
Please sign in the space provided in order to avoid delays in processing your request.
A signature guarantee is required if plan sponsor approval of the distribution is not required in STEP 9 and
• the amount of the distribution is $100,000 or more OR
• the distribution is not sent to the address of record OR
• your address has changed within the last 15 days
The requirement for a signature guarantee is NOT applicable when the distribution amount is $100,000 or more if (i) you are rolling the distribution
over to a Fidelity retirement account AND (ii) the name and address on both accounts are the same. All other signature guarantee requirements are
still applicable.
You may obtain a Medallion signature guarantee or any other signature guarantee for at least the estimated value of your distribution by contacting a
Fidelity Investor Center, a National or State Bank, Savings Banks in NY and MA, Trust Companies, Federal Savings and Loan Associations, Members of
the New York, American, Boston, Midwest or Pacific Stock Exchanges. Many of these organizations may participate in the Medallion signature guarantee
program.
When you obtain a signature guarantee, please tell the person that provides the signature guarantee of the estimated amount of the distribution and
ask if the signature guarantee that he/she is providing is sufficient for the transferred amount. If the signature guarantee that you obtain is not a
Medallion signature guarantee, please include the name and telephone number of the person who supplies the signature guarantee. Please note that a
notarized signature is not a substitute for a signature guarantee.
A medallion signature guarantee contains a number with a letter prefix. The prefix letter presents the degree of liability the guarantor is willing to
assume. The degree of liability and the transaction amount must correspond to the letter prefix. If the letter prefix does not match the degree of liability, your distribution request will be returned for the proper letter prefix. Please see the following table:
Medallion Prefix
Degree of Liability
X
Up to $2,000,000 and above
A
Up to $1,000,000
B
Up to $750,000
C
Up to $500,000
D
Up to $250,000
E*
Up to $100,000
F*
Up to $100,000 (Credit Unions)
*Please note medallion signature guarantees with the letter prefix of E or F are only required if your address has changed
within the last 15 days; or your distribution amount is less than $100,000, and you request that your check to be sent to a
different address than the address of record.
STEP 9 PLAN SPONSOR APPROVAL
Although you may no longer be employed by the plan sponsor in Step 1, you may still be required to obtain their approval. Please ask a
Fidelity Retirement Services Specialist or the employer sponsoring the plan if their approval is required.
Please ensure that the individual signing your distribution form on behalf of the plan sponsor is authorized to do so.
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318082
Fidelity Investments Institutional Operations Company, Inc.
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1.780607.100