060173_U113_IRA PWS_Form.indd

Fidelity IRA Personal Withdrawal Service Form Customer Instructions, Terms and Conditions Use this form to establish a new, or update or delete an existing, Personal Withdrawal Service (PWS) plan to a Traditional, Roth, SEP, or SIMPLE IRA. Because of unique withholding requirements, PWS plans are not available to nonresident aliens. Do not use this form for distributions from inherited IRA accounts. You must first transfer inherited IRA assets to an IRA Beneficiary Distribution Account or Roth IRA Beneficiary Distribution Account (“IRA-BDA”), as applicable, and then take the death distributions from the IRA-BDA. Also do not complete this form if you wish to request a transfer pursuant to a divorce of the IRA owner or if you are a spouse beneficiary and you wish to transfer the decedent’s IRA to your own IRA. For Inherited IRA distributions, call a Fidelity Retirement Representative at 1-800-544-4774 from 8 a.m. to 8 p.m. ET or visit Fidelity.com/goto/inheritedira. For Minimum Required Distributions (MRDs), return this form no later than December 15 or March 15, as applicable, to allow adequate time for processing. Fidelity cannot assume responsibility for making your distribution by the April 1 IRS deadline for your initial MRD or the December 31 deadline for subsequent year MRDs. If you are requesting distributions to meet a Minimum Required Distribution or a Substantially Equal Periodic Payment, it is your responsibility to ensure that your distributions satisfy IRS requirements. Please consult a tax advisor to ensure that your payments will meet the requirements. Failure to satisfy your MRD requirements may result in an IRS penalty of up to 50% of the difference between the MRD amount you should have taken and the amount actually withdrawn. Fidelity cannot accept responsibility if we are unable to make your scheduled distribution based on the instructions you provide, due to insufficient funds in your account. When you withdraw the entire balance from your IRA, a closeout fee may apply. Back-end loads, redemption fees or transaction fees may also apply to mutual fund distributions. Please refer to the IRA Schedule of Fees in the Supplemental Information and the fund’s prospectus for details. Return the completed form to: Fidelity Investments, Attn: Retirement Distributions, P.O. Box 770001, Cincinnati, OH 45277-0035. If you have additional questions, visit Fidelity.com/retirement or call a Fidelity Retirement Representative at 1-800-544-4774 from 8 a.m. to 8 p.m. ET. When completing the form, please use a pen and print clearly. 1 CUSTOMER INFORMATION Mark the appropriate checkbox and complete Sections 1 through 8. If you are establishing a new plan for your Portfolio Advisory Services IRA account(s), do not complete Section 6 – Designating Accounts & Positions for Taking Your Periodic Withdrawals. First mark the appropriate box to establish a new PWS plan, or to change or delete an existing PWS plan. To establish a new PWS plan To change an existing PWS plan Mark the appropriate checkbox, and complete Sections 1 and 8 and any additional relevant sections only. If you are changing an existing PWS plan that is one of multiple PWS plans for the Fidelity IRA indicated, make sure to indicate the specific plan you wish to change. If you are changing an existing withdrawal plan for your Portfolio Advisory Services IRA account(s), do not complete Section 6 – Designating Accounts & Positions for Taking Your Periodic Withdrawals. To delete an existing PWS plan Mark the appropriate checkbox and complete Sections 1 and 8. Next, please check either the box labeled non-Roth IRA (includes Traditional, Rollover, SEP, and SIMPLE IRAs) or Roth IRA, provide your name, one of your Fidelity IRA account numbers for identification purposes, your Social Security number, date of birth and a contact number. Due to IRS regulations, you may not mix non-Roth and Roth IRAs in a single PWS plan. You must complete two separate forms if you wish to establish plans for both non-Roth IRA(s) and Roth IRA(s). 2 REASON FOR WITHDRAWAL Please indicate the reason for this distribution – choose only one reason. Fidelity must report all IRA distributions to the IRS. If nothing is checked, your distributions could be improperly reported or delayed. Check the appropriate box to reflect the reason for your withdrawal request to ensure appropriate reporting for your IRA distribution. Note that if you are under age 59½ and are taking distributions for a qualified first-time home purchase ($10,000 lifetime total), qualified higher education expenses, certain medical expenses or health insurance premiums as defined in the Internal Revenue Code section 72(t), mark the box for “Early Distribution.” Page 1 If you indicate Substantially Equal Periodic Payments as your reason for withdrawal, it will be reported to the IRS as “early distribution – no known exception applies.” If you qualify for an exception to the tax on premature distribution, you must file IRS form 5329 with your tax return. Please consult with your tax advisor when establishing or making changes to a Substantially Equal Periodic Payment plan. Note: If you are taking a withdrawal from your Roth IRA, do not check the Substantially Equal Periodic Payment (“SEPP”) box. Checking the SEPP box for Roth IRAs will result in Fidelity reporting a distribution as an early distribution. If you check SEPPs in Section 2, in Section 3 you must choose Option C – Substantially Equal Periodic Payments (SEPPs), either the Amortization Method or the Life Expectancy (MRD) Method. Establishing or making changes to a SEPP plan should be discussed with your tax advisor. You may be required to file IRS Form 5329 if you made withdrawals before age 59½ for one of the following reasons: medical, first-time home purchase, qualified higher education expenses, or SEPPs. If you made an early withdrawal for reasons other than these, you may still be required to file IRS Form 5329 (used for paying and waiving penalties). Early Withdrawals from SIMPLE IRAs: Distributions from SIMPLE IRAs in the first two years of participation and prior to age 59½ may be subject to an increased penalty from 10% to 25% imposed by the IRS. The two-year period begins on the day contributions are first deposited. 3 CALCULATING YOUR WITHDRAWAL AMOUNT Select one of the three options for this section and complete all requested information for that option. Additional information on each option is listed below. You have the option to calculate your withdrawal amount using any or all of your Fidelity IRA account(s) including Fidelity Funds IRA account(s), Fidelity Brokerage IRA account(s) and Fidelity Portfolio Advisory Services (PAS®) IRA accounts. OPTION A: MINIMUM REQUIRED DISTRIBUTION (MRD/LIFE EXPECTANCY DISTRIBUTION) MRDs can be requested for Traditional IRAs, Rollover IRAs, SEP-IRAs and SIMPLE IRAs held under your Social Security number. MRDs do not apply to Roth IRAs during your lifetime, but certain distribution rules apply after your death. IRS regulations specify that MRD calculations are generally based upon the Uniform Lifetime Table (uses your age to determine the number of years and amount of your distribution). For reference, this table is included in the IRA Minimum Required Distribution Guide. The calculation is also based on the assets in your Fidelity IRA account(s) as of the prior December 31 adjusted for outstanding rollovers and transfers. The Spousal Exception Joint Life Expectancy Table is used to calculate your MRD if your current Fidelity beneficiary designation names a spouse who is more than ten years younger than you as sole primary beneficiary. This table is also available online at Fidelity.com. Fidelity will calculate your MRD using all of the Fidelity IRA accounts you indicate in Section 3 (not including Roth IRAs or Inherited IRAs (IRA BDAs))held under your Social Security number. If you maintain IRAs at other institutions, you are required to calculate your MRD for your non-Fidelity IRA accounts separately. Each account’s MRD is calculated based on the applicable IRS table, either Spousal Exception Joint Life Expectancy Table or Uniform Lifetime Table, then aggregated together as the MRD amount for all the accounts in the automatic withdrawal plan. At the beginning of each subsequent year Fidelity will make a determination if the spousal exception applies based on your beneficiary designations at the beginning of the year, and if applicable, use the Spousal Exception Joint Life Expectancy Table for that year’s MRD calculation. Under IRS rules, use of the Spousal Consent Table is limited to marriages recognized under federal law. OPTION A – ADJUSTMENTS: The boxes you select in this section will be used in your MRD calculation. If you have any pending year-end rollovers or transfers, please check the first box in Section 3, Option A and write in the market value for last year’s 12/31 outstanding rollover, transfer, or if applicable, recharacterized contribution. Please check the second box if you deferred your first-year MRD payment last year, and provide the 12/31 market value of these items from two years ago. The December 31 market value of each of your retirement accounts should be adjusted for any pending year-end transfers or rollovers. For example, if assets were withdrawn from an IRA or qualified employer-sponsored plan within the last 60 days of the prior calendar year, and a portion or all of those assets were rolled over to a Fidelity IRA this year, you must add the amount of the rollover to the balance of your Fidelity IRA as of December 31 of the prior year. This may also apply to year-end transfers not credited to your account until after December 31 unless the MRD attributable to the amount transferred was distributed from another IRA. Spousal Exception: Check the box to direct Fidelity to use the Spousal Exception Joint Life Expectancy Table to calculate your MRD if your current Fidelity beneficiary designation names a spouse who is more than ten years younger than you as sole primary beneficiary. This table is also included in the IRA Minimum Required Distribution Guide for reference purposes. If this box is not checked, your MRD calculation will be based on the Uniform Lifetime Table for the current year. Page 2 Important: Keep your beneficiary information current to ensure proper calculations are performed. Fidelity will not automatically update your MRD withdrawal plan until January of the year following the year in which you make a beneficiary change. Because of this, it may be necessary for you to take an additional withdrawal to satisfy your MRD amount in the year of a beneficiary change to avoid a possible penalty tax. Please consult your tax advisor to determine how a beneficiary change may affect your individual situation. You can review your current beneficiary designation at Fidelity.com under “Your Profile/Beneficiaries,” by checking Form 5498 that is mailed to you each February, or by calling a Fidelity Retirement Representative at 1-800-544-4774 between 8 a.m. and 8 p.m. ET. For your convenience, we have enclosed a Beneficiary Form within the IRA Minimum Required Distribution Guide should you need to make any changes. A revised account profile will be sent to you upon establishment of this PWS plan and in January of each year thereafter confirming the MRD amount to be distributed under the plan for that year. If the Spousal Exception is applied, the Account Profile will state the name of your spouse beneficiary. Notes about payments: • If you are establishing your Personal Withdrawal Service plan mid-year, your entire MRD distribution for the current year will be paid out evenly over the remaining number of scheduled payments in the year. • If you would like your distribution amount adjusted for distributions already taken within the applicable distribution year, you must notify Fidelity in writing of the date(s) and the distribution amount(s) already taken through a letter of instruction. OPTION B: GENERAL PURPOSE PLAN If you are setting up a PWS plan, but do not wish to establish an MRD or SEPP plan, please complete this section. You must indicate a withdrawal amount (Option B1 – Fixed Amount Per Withdrawal) or method of calculation (Option B2 – Fixed Period Calculation). Option B1 – Fixed Amount Per Withdrawal: Withdraws the amount you indicate for each payment. Option B2 – Fixed Period Calculation: This option depletes the entire balance of your Fidelity IRA(s) over the number of years you specify. Do not use this for MRD purposes. First, specify the accounts to be included in your Fixed Period calculation – either all of your accounts, or only those accounts you enter into the boxes provided. Second, enter in the number of years over which you want to receive payments. Fidelity will calculate the amount of each payment by dividing the total Fidelity IRA account balance by the remaining number of payments, which is based on the information you provide in Section 5. Fidelity will use the total balance of your eligible mutual fund positions in your Fidelity IRA accounts within a few days before the distribution is scheduled, depending on the number of settlement days required, normally to a maximum of seven days. OPTION C: CALCULATION OPTIONS FOR SUBSTANTIALLY EQUAL PERIODIC PAYMENTS (SEPPs) You must be under age 59½ to be eligible for SEPPs. Per IRS regulations, only one IRA account per SEPP plan is allowed; applicable IRA accounts include Traditional IRAs, Rollover IRAs, SEP-IRAs, SIMPLE IRAs, and Roth IRAs, but not Inherited IRAs held under your Social Security number. You may choose from three options to calculate your periodic payment. If you know the amount to withdraw, select Option B1 – Fixed Amount per Withdrawal. If you want Fidelity to calculate your payments, complete either Option C1 – Amortization Method, or C2 – Life Expectancy (MRD) Method. Once payments begin, they must continue for at least five years or until you reach 59½, whichever is longer. If you are instructing Fidelity to change the method by which your SEPP payments are calculated, complete this PWS Request form as if you are doing the new method, and make sure to check the box (Section 1) indicating this is a change to an existing PWS plan. Note: The IRS only permits a change on an existing Fixed Amount Calculation Method plan (Amortization or Annuity Method) to the MRD method. Any other changes will generally trigger early withdrawal penalties. If the changes you are submitting on this form decrease the SEPP payment you will receive, and, in the current year, you have already received distributions greater than the annual amount of your revised SEPP calculation, the changes will not begin until the following year’s distribution. If you are taking SEPPs, you must comply with all IRS rules with regard to SEPPs including restrictions to any addition(s) to the account balance, any nontaxable transfer of a portion of the account balance to another retirement plan, or rollover of the amount received resulting in such amount not being taxable. Please consult with your tax advisor when establishing or making changes to a Substantially Equal Periodic Payment plan. All SEPP distributions are reported to the IRS as “early distributions, no known exception applies.” If you are currently taking Substantially Equal Periodic Payments from another company or custodian and are transferring the balance to Fidelity, please call a Retirement Representative at 1-800-544-4774 from 8 a.m. to 8 p.m. ET to discuss your specific situation. Option C1 – Amortization Method: Fidelity will calculate the amount of your withdrawals by amortizing your total Fidelity IRA account balance as of December 31 of last year over the remainder of the period using a beginning-of-period assumption, and based on your life expectancy or the joint life expectancy of you and your beneficiary and the assumed rate of return you specify, Page 3 which may be more or less than your actual investment return. (IRS guidelines provide that the interest rate used be not more than 120% of the federal mid-term rate for either of the two months immediately preceding the month distributions begin.) Fidelity must have your beneficiary designation on file for joint calculations. Please specify the account to be included in the SEPP calculation (Fidelity allows only one Fidelity IRA account per SEPP plan). Note that you must distribute from the same account used in the calculation. Option C2 – Life Expectancy (MRD) Method: Fidelity will calculate the amount of your withdrawals using the Single Life Expectancy table. Specify the account number you wish to use in the calculation (only one account allowed per SEPP plan). Note: There are other IRS approved Life Expectancy tables available, but for SEPP calculations Fidelity only supports Single Life Expectancy for PWS plans. OPTION C – OPTIONAL ELECTIONS: If you have any pending year-end rollovers or transfers that you want considered in your calculation, please check the appropriate box in Section 3, Option B and write in the market value for last year’s 12/31 outstanding rollover, transfer, or recharacterized contribution. 4 TAX WITHHOLDING ELECTION Federal Tax Withholding You may elect not to have federal withholding apply (provided you have supplied Fidelity with a U.S. address), or you may elect to increase the rate of withholding. If left blank, IRS regulations require Fidelity to withhold federal income tax at a rate of 10% from your total IRA distribution (excluding Roth IRA distributions). This applies even if you have made nondeductible contributions to your IRA and may result in excess taxes taken from your distribution. State Tax Withholding If federal income tax withholding is applied to your distribution, state income tax may also apply. The state income tax withholding requirements your distribution will be subject to, if any, are determined by the legal address of record on your Fidelity IRA. If you have a Roth IRA, paying state taxes is voluntary except in the following states, where you may not elect to pay state tax: AK, FL, HI, MS, NH, NV, PR, SD, TN, TX, WA and WY. Please review the state tax information provided below. If a minimum state tax applies, Fidelity will withhold taxes at the greater of the minimum state tax or the amount you specify. Residents of AR, IA, KS, MA, ME, OK, and VT If federal income tax is withheld, state income tax of at least your state’s minimum requirements must be also withheld at the time of your distribution. If you elect out of federal income tax withholding, state income tax will not be withheld unless you indicate otherwise. If you are setting up or changing a Personal Withdrawal Service for a Roth IRA, we will not set up the plan for state tax withholding unless it is specifically requested. Roth IRA: State taxation is voluntary. Residents of CA, DE, NC and OR If federal income tax is withheld, state income tax of at least your state’s minimum requirements must also be withheld at the time of your distribution unless you indicate you do not want to withhold state tax. If you elect out of federal income tax withholding, state income tax will not be withheld unless you indicate otherwise. Roth IRA: State taxation is voluntary. Residents of AK, FL, HI, MS, NH, NV, PR, SD, TN, TX, WA and WY Residents of all other states and the District of Columbia You may not elect state tax withholding (for non-Roth and Roth IRAs). State income tax withholding is not available on your IRA distributions. Please consult your tax advisor, state agency, or investment representative for more information. You may elect voluntary state income tax withholding. You must provide a percentage to be applied for state tax withholding. Roth IRA: State taxation is voluntary. Whether or not you elect to have federal or state taxes withheld from your distribution, you are responsible for the full payment of federal income tax, any state or local taxes, and any penalties which may apply. You may be responsible for estimated tax payments and could incur penalties if your estimated tax payments are not sufficient. Your election will remain in effect on periodic distributions taken under this systematic withdrawal plan from your Fidelity IRA account(s) until revoked by you. You can revoke this election for future distributions at any time by phone or written request. Page 4 5 FREQUENCY OF WITHDRAWALS Please write in the day of the month on which you want withdrawals to be made from your account, and write in the specific date – day, month, and year – of your first distribution payment. Then select whether you wish to have equal monthly payments throughout the year, or specify the months when you want to receive distributions by checking the appropriate boxes. Periodic withdrawal payments will not be permitted more often than once per month. Section 5 – Optional Elections (only to be used if you selected MRD in Section 3): Deferral of First Year MRD – When you turn 70½, you have the option of deferring your first MRD until the following year between January 1 and April 1. • If you turned 70½ this year and you wish to defer your first-year MRD until next year (between January 1 and April 1), check the box and fill in the date you wish to have your first MRD distribution made in the space at the bottom of Section 5 – Frequency of Withdrawals. Subsequent years’ payments would then be made according to the instructions you provided in the first part of Section 5. • If you turned 70½ last year and need to take your first MRD amount by April 1 of this year, check the applicable box and indicate the date you wish to have your first-year MRD distribution made in the space at the bottom of Section 5. If you elect to defer your first-year MRD, your second-year payments will begin on the date of the first-year MRD payment, and your entire MRD distribution for that year will be paid out evenly over the remaining number of monthly payments you have scheduled for the year. After that time, payments will be made as you specified in this section. Note: Withdrawals from any IRA that are scheduled to be paid out in December may result in your payment being processed prior to the date selected to help ensure that your withdrawal is processed prior to year-end. 6 DESIGNATING ACCOUNTS & POSITIONS FOR TAKING YOUR PERIODIC WITHDRAWALS Note: When specifying from which accounts to fund your withdrawal, be aware that only those accounts that are included in the Calculation specified in Section 3 can be included in the funding of withdrawals in this section. OPTION A: PROPORTIONAL WITHDRAWALS For proportional withdrawals, liquidations will be taken from all eligible mutual fund and core positions including money market funds based on the amount calculated in Section 3. Eligible mutual funds include all Fidelity funds that are available to Retail customers and also funds available through Fidelity FundsNetwork® where the mutual fund company has agreed to make the fund available for distributions through a systematic withdrawal plan. Select Option A-1 if you would like your withdrawals taken proportionately from all your Fidelity IRAs. Select Option A-2 if you would like to specify one or more accounts from which to take your withdrawals proportionately. Enter one or more account numbers in the space provided. Note for Portfolio Advisory Services (PAS) account holders – If any of your Fidelity IRAs are in accounts managed by PAS: • For each withdrawal, PAS will make every effort to maintain the appropriate asset allocation of your PAS account. • In order to use proportional withdrawals for PAS accounts, you must also include at least one other non-PAS account in the proportional calculation. Example of Proportional Calculation: If you have two IRA accounts at Fidelity and you select Option A-1, withdrawals from both of these accounts will be proportioned based on the value of the eligible fund positions including the core position held by each account. OPTION B: FIXED PERCENT OR FIXED AMOUNT DESIGNATIONS Choose this option if you wish to make withdrawals by liquidating the specified fixed percent or fixed dollar amount(s) from your Fidelity IRA account number(s), mutual funds and core position(s) provided in this section. Provide the position name, and percentage or dollar amount for each position indicated. Note that dollar amount(s) should only be used for Fixed Amount plans (specified in Section 3, Option B1) and should not be elected for MRD plans or SEPP plans using the Life Expectancy (MRD) method. The PWS plan will sell the amount requested from the mutual funds specified and then, if necessary, attempt to fund the remaining distribution amount from the core position. If the plan includes a PAS account, the process will attempt to fund any remaining distribution amount from the PAS account request. Secondary Withdrawal Instructions If there are insufficient funds in the positions designated in your primary withdrawal instructions, choose A or B to indicate how the distribution should then occur. If you do not specify your Secondary Withdrawal instructions, Fidelity will automatically assume Option B. Page 5 The Fidelity PWS plan will execute the secondary instructions in the following order, based on type of account(s) specified for the plan: Mutual Fund accounts first, then Brokerage accounts, then accounts managed by Portfolio Advisory Services (PAS). The plan will attempt to fund up to the remaining distribution amount from the core position. If the plan includes PAS account(s), the process will attempt to fund any remaining distribution amount from the PAS account without regard to the PAS account’s core position balance. Option A: Any money market fund. You are instructing us to attempt to make the distribution by making funds available through the liquidation of money market fund(s) in the same IRA(s), beginning with the funds with the lowest balance. If two eligible funds have identical balances, we will liquidate the funds with the lowest CUSIP.** Option B: Any money market, bond, or equity funds. You are instructing us to attempt to make the distribution by making funds available through the liquidation of money market fund in the same IRA(s), beginning with the money market fund with the lowest balance. If sufficient funds are not available from money market funds, you are instructing us to attempt to make the distribution by making funds available through the liquidation of bond or equity funds in the same IRA, beginning with the bond or equity funds with the lowest balance. If two eligible funds have identical balances, we will liquidate the position with the lowest CUSIP.* *Note: Choosing this option may result in the full distribution not being made. **CUSIP numbers (along with symbols) are assigned by the Committee on Uniform Securities Identification Procedures to all securities, and are used for identification when recording buy and sell orders. Note: Certain Fidelity mutual funds have been closed to new investors. If one of these funds is subject to your withdrawal instructions, be aware that your position could be fully liquidated, and this may prohibit you from future investments in the fund. 7 PAYMENT METHOD Choose one of the four options for receiving your withdrawal payments and complete any additional information requested for that option. If no option is selected, a check will be sent to your address of record. A. Direct deposit into your nonretirement Fidelity Brokerage or Fidelity Funds account (if you do not have a Fidelity nonretirement account, one can be established today at Fidelity.com, or call us at 1-800-544-4774 to obtain an application). Please mark the checkbox if you are establishing a new account and complete the application enclosed. The usual account minimum requirement is waived if your account is funded through a PWS plan. Distributions to a Fidelity Brokerage account are invested into your core position. If you have a Fidelity Mutual Fund IRA, please specify the fund you wish to invest your distribution into on the line provided. B. Deposited electronically into your bank or credit union account using Electronic Funds Transfer (EFT). Allow at least 10 days for EFT to become active. Once established, allow 2–3 days for funds to reach your bank or credit union. The recipient institution must be a member of the Automated Clearing House. Attach a voided check to supply your bank information. Fidelity does not charge for using EFT services. The maximum amount that may be sent via EFT is $100,000 per distribution. Include a voided check and complete the requested information to establish EFT or to confirm existing EFT instructions. If you are unsure of any of the information, please verify with your bank or credit union. C. By check to your address of record. D. By check to an alternate address (a signature guarantee is required for this option, see Section 8). Note: If you select Option A or B and the transaction cannot be completed using this Payment Method, the system will default to sending a check to the address of record. 8 AUTHORIZATION AND SIGNATURE Read the authorization and sign as indicated. A SIGNATURE GUARANTEE is required if your: • Withdrawal exceeds $100,000.00 per payment, or • Current address of record has been on file less than 15 days, or • Check is being sent to an address other than your address of record. A signature guarantee is designed to protect you and Fidelity from fraud. You should be able to obtain a signature guarantee from a bank, broker, broker/dealer, credit union (if authorized under state law), securities exchange or association, clearing agency or savings association. A notary public cannot provide a signature guarantee, and a notarization cannot be accepted in lieu of a signature guarantee. Page 6 Fidelity IRA Personal Withdrawal Service Form (including Minimum Required Distribution) Please read the attached Customer Instructions, Terms and Conditions before completing this form. Additional information is available at Fidelity.com/retirement or by calling a Retirement Representative at 1-800-544-4774 between 8 a.m. and 8 p.m. ET. Return the completed form to: Fidelity Investments, Attn: Retirement Distributions, P.O. Box 770001, Cincinnati, OH 45277-0035. Please use a pen and print clearly. 1 CUSTOMER INFORMATION Check this box to establish a new Fidelity IRA Personal Withdrawal Service plan. Check this box to change an existing Fidelity IRA Personal Withdrawal Service plan. Check this box if you wish to delete an existing Fidelity IRA Personal Withdrawal Service plan previously established for the Fidelity IRA identified below. (Remember to provide your signature at the end of this form.) First Name: Last Name: Date of Birth: Social Security Number: Contact Tel. No.: – Fidelity Account Number: (Specify any one of your Fidelity IRA account numbers to assist us in processing your request.) IRA Type (check one): Middle Initial: Non-Roth IRA (includes Traditional, Rollover, SEP, and SIMPLE IRAs) Roth IRA This form may be used to establish, change, or delete PWS plans for either non-Roth IRA accounts or Roth IRA accounts, but not both. Check here if this is a Personal Withdrawal Service request for a Fidelity Portfolio Advisory Services (PAS) Retirement account. 2 REASON FOR WITHDRAWAL – CHOOSE ONE Normal (includes MRD); I will be at least age 59½ on the date of my first distribution. Disability; I am disabled (as defined by the Internal Revenue Service) and will be less than age 59½ on the date of my first distribution. Early Distribution; I will be less than age 59½ and not disabled or taking Substantially Equal Periodic Payments (SEPPs) on the date of my first distribution. Important: The IRS may impose a penalty for early withdrawals. Substantially Equal Periodic Payments (SEPPs); I will be less than age 59½ on the date of my first distribution and will continue this distribution schedule for the greater of five years or until I reach age 59½. I understand Fidelity will report SEPP distributions as “Early Distributions, no known exception applies.” Note: A distribution from a Roth IRA will be reported as an early distribution. 1.808820.109 Page 1 of 6 012160201 3 CALCULATING YOUR WITHDRAWAL AMOUNT – CHOOSE ONE In this section you have the option to calculate your withdrawal amount using any or all of your Fidelity IRA account(s), including Fidelity Funds IRA accounts, Fidelity Brokerage IRA accounts and Fidelity Portfolio Advisory Services (PAS) IRA accounts. These instructions will only be used to calculate your withdrawal amount, not to identify the accounts that will be the source of your withdrawals. Option A: Minimum Required Distribution (MRD) I want Fidelity to calculate my MRD withdrawal amount using: Specify account(s) to use – I wish to calculate my withdrawal amounts using (choose one): All of my non-Roth Fidelity IRA accounts under my Social Security number OR Only the following IRA account numbers. (This calculation may include multiple IRA accounts, including Fidelity Funds IRAs, Fidelity PAS IRAs, and Fidelity Brokerage IRAs, and non-Roth IRAs, including Traditional IRAs). ADJUSTMENTS Check the box for any situation that applies to you and that should be used in your MRD calculation: I transferred, rolled over, or recharacterized IRA assets to Fidelity last year that were pending and not included in last year’s 12/31 market value in the amount of $ _______________. I deferred my first MRD payment last year, and had transferred, rolled over, or recharacterized IRA assets to Fidelity two years previously that were pending and not included in the prior year’s 12/31 market value in the amount of $ _______________. Option B: General Purpose Plan (choose one) Option B1 – Fixed Amount Per Withdrawal: $ (I will provide the applicable period in Section 5), OR Option B2 – Fixed Period Calculation: 1) Deplete the entire balance of my account over years. 2) Specify account(s) to use – I wish to calculate my withdrawal amounts using (choose one): All of my Fidelity IRA accounts under my Social Security number (either Roth or non-Roth IRA) OR Only the following IRA account numbers. (This calculation may include multiple accounts, including Fidelity Funds, Fidelity PAS IRAs, and Fidelity Brokerage IRAs, either Roth or non-Roth IRA, including Traditional): 1.808820.109 Page 2 of 6 012160202 3 CALCULATING YOUR WITHDRAWAL AMOUNT – CHOOSE ONE (CONTINUED) Option C: Substantially Equal Periodic Payments (SEPPs) I will be under the age of 59½ on the date of my first withdrawal and plan to continue this SEPP plan until the later of five years or age 59½. (choose one) Option C1 – Amortization Method. Fidelity will calculate my payments using the Amortization Method and the following assumptions as specified by me: 1) Specify the account number (only one allowed per plan): 2) Assumed rate of return: guidelines) My single life expectancy % (see instructions for information on Internal Revenue Service 3) Indicate what life expectancy the calculation should be based on: The joint life expectancy of my designated beneficiary and me Option C2 – Life Expectancy (MRD) Method. Note: This calculation will use the Single Life Expectancy table. Specify the account number (only one allowed per plan): Include last year’s 12/31 market value of an outstanding rollover, transfer, or recharacterization amount of $___________ in the calculation. 4 TAX WITHHOLDING ELECTION Federal Tax Withholding Check one of the following to indicate whether you wish to have federal income taxes withheld. If no box is checked, Fidelity is required to withhold 10% from the gross distribution (excluding Roth IRAs). I elect NOT to have federal taxes withheld. State Tax Withholding Check one of the following to indicate whether you wish to have state income taxes withheld. State tax withholding may apply even if you do not check a box below, and some states do not allow state tax withholding. Also, if your state has a minimum tax rate, we will withhold taxes at the greater of the minimum or the amount you specify below. Refer to the instructions for specific information concerning your state. I elect NOT to have state taxes withheld. I elect to have state taxes withheld at the rate of (specify a whole number percentage). % I elect to have federal taxes withheld at the rate of (specify a whole number percentage between 10 and 99). % 5 FREQUENCY OF WITHDRAWALS I would like my withdrawals made on the frequency indicated below, starting: Frequency: Monthly OR Other, on the following months: / / . Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Optional Elections: Complete the following if you turned 701⁄2. I turned 701⁄2 this year and: I would like to defer my first MRD until next year on the date specified below. I turned 701⁄2 last year and: I need to take my first MRD amount by April 1 of this year, on the date specified below. 1.808820.109 Page 3 of 6 012160203 5 FREQUENCY OF WITHDRAWALS (CONTINUED) Optional: Note: Deferral of First-Year MRD – When you turn 701⁄2, you have the option of deferring your first MRD until the following calendar year between January 1 and April 1. To elect this option, check below: Calculate and distribute my first-year MRD as a lump-sum amount on (Month/Day) ______________________ (Jan 1 – Apr 1 only) Note: For those deferring their first-year MRD, the second-year payments would commence on the date of the first-year MRD payment, and your entire MRD distribution for the current year will be paid out evenly over the remaining number of scheduled payments in the year. Payments would then be made as requested in subsequent years. 6 DESIGNATING ACCOUNTS & POSITIONS FOR TAKING YOUR PERIODIC WITHDRAWALS Please complete either Option A or Option B. If this section is left blank, Fidelity will automatically assume Option A-1 – proportional withdrawals liquidated from all your Fidelity IRAs. Refer to the instructions for further information on funding your withdrawals. Note: When specifying from which accounts to make your withdrawal, be aware that only those accounts that are included in the calculation specified in Section 3 can be included in withdrawals in this section. If this request for Periodic Withdrawals only includes distributions from a Fidelity Portfolio Advisory Services IRA account, you do not need to complete this section. Option A: Proportional Withdrawals* (choose A-1 or A-2) For proportional withdrawals, liquidations will be taken from all eligible mutual fund positions, including money market and core positions. Your Periodic Withdrawals will not be taken from non–mutual fund or core positions. A-1. Please make withdrawals proportionally from all my Fidelity IRAs. A-2. Please make withdrawals proportionally from my following Fidelity IRAs only: Account Numbers Account Numbers *If any of your IRAs are in accounts managed by Portfolio Advisory Services (PAS), for each withdrawal request, PAS will make every effort to maintain the appropriate asset allocation of your PAS account. Also, proportional withdrawals are only allowed for PAS accounts when there are also non-PAS accounts included. Option B: Fixed Percent or Fixed Amount Designations Please make withdrawals by liquidating the specified fixed percent or fixed dollar amount(s) from my Fidelity IRA account number(s) and mutual fund and core position(s) listed below. Dollar amount(s) should only be used for Fixed Amount plans and should not be elected for MRD plans or Substantially Equal Periodic Payment (SEPP) plans using the Life Expectancy (MRD) method. 1.808820.109 Page 4 of 6 012160204 6 DESIGNATING ACCOUNTS & POSITIONS FOR TAKING YOUR PERIODIC WITHDRAWALS (CONTINUED) Note: For accounts managed by Portfolio Advisory Services (PAS), do not indicate the Mutual Fund position below. For each withdrawal request, PAS will make every effort to maintain the appropriate asset allocation of your PAS account. Account Number Mutual Fund Name Fixed Percent OR Fixed Dollar Amount % % % % % Secondary Withdrawal Instructions: (for Fixed Percent or Fixed Amount designations, you must elect one of the following) $ $ $ $ $ If you do not specify Secondary Withdrawal Instructions, Fidelity will automatically assume Option B, “Any eligible mutual fund, money market, bond fund, or equity fund position.” Note: Does not apply to accounts managed by Portfolio Advisory Services (PAS). A. Any money market or core position OR B. Any money market, bond fund, equity fund or core position 7 PAYMENT METHOD – CHOOSE ONE A. Directly deposited to my Fidelity nonretirement account: Account Number New Account (application enclosed) Distributions to a Fidelity Brokerage account are invested into your core account. If you have a Fidelity Mutual Fund account, please specify the fund you wish to invest your distribution in: B. Deposited electronically into my bank or credit union account using Electronic Funds Transfer (EFT). Account Type: Checking Savings (non-passbook) Please provide bank information and attach a voided check to this page. Signature Guarantee required if a voided check not attached. Your Bank’s Name: Bank Routing Number: Name(s) on Bank Account: C. By check to be sent to my address of record. D. By check to be sent to me at an alternate address (signature guarantee required – see below). Bank Account Number: Street Address City State Zip Code 1.808820.109 Page 5 of 6 012160205 8 REQUIRED SIGNATURES I authorize and request the custodian for the Fidelity IRA, Fidelity Management Trust Company and its agents, affiliates, employees, or successor custodians (“Fidelity”), or Portfolio Advisory Services through National Financial Services LLC, to make the above withdrawals. I understand that non-Roth IRA withdrawals will be taxed as ordinary income, and may be subject to a 10% early withdrawal penalty if taken before age 59½. I understand that I may be subject to a 25% withdrawal penalty on withdrawals made from my SIMPLE IRA prior to age 59½ and within the first two years of participating in an employer’s SIMPLE IRA plan. If I am taking Substantially Equal Periodic Payments (“SEPP”), I accept full responsibility for complying with the IRS rules. I understand that certain transactions may result in the disqualification of my SEPP plan. I further understand that Fidelity reports my SEPP distributions in accordance with Internal Revenue Service requirements as an early distribution – no known exception applies. If I am over age 70½, I accept full responsibility for withdrawing from my Traditional, Rollover, SEP, or SIMPLE IRA the minimum required distribution required by Section 401(a)(9) and 408 (a)(6) of the Internal Revenue Code and applicable regulation. I indemnify the Custodian for the Fidelity IRA, its agents, successors, affiliates, and employees from any liability in the event that I fail to meet the IRS requirements. I acknowledge that I received, read, and understand the Fidelity IRA Personal Withdrawal Service Form Instructions attached to this form. If I elect the EFT feature, I hereby authorize and request Fidelity to make distributions from or contributions to the Fidelity IRA listed above by initiating debit or credit entries to the account indicated above. I authorize and request the bank named above (“BANK”) to accept any such debit and credit entries initiated by Fidelity in such account and to debit and credit the same account without responsibility for the appropriateness thereof or for the existence of any further authorization relating hereto. I hereby ratify any telephone instructions given pursuant to this authorization and agree Fidelity will not be liable for any losses resulting from unauthorized transactions if it follows reasonable procedures designed to verify the identity of the caller. I further consent to the tape recording of all instructions given by telephone. I hereby certify under penalties of perjury that I am a U.S. citizen or other U.S. person (including a resident alien individual) and that the Social Security number shown in the Customer Information section of this form is my correct tax identification number. If indicated above that my spouse beneficiary who is more than 10 years younger than I has been my sole beneficiary for the entire calendar year, I hereby certify that statement is correct as to the accounts covered by this PWS MRD Plan, and I am aware that he or she must be the sole beneficiary on the accounts covered by this PWS MRD Plan for the entire calendar year to be eligible to have that year’s MRD calculation based upon the Spousal Exception Table. PRINT NAME SIGNATURE GUARANTEE STAMP SIGNATURE OF OWNER Date X See instructions for signature guarantee requirements. A notary public cannot provide a signature guarantee. We cannot accept a notarization instead of a signature guarantee. Fidelity Distributors Corporation Fidelity Brokerage Services LLC, Member NYSE, SIPC Fidelity Portfolio Advisory Service® is a service of Strategic Advisers, Inc., a registered investment adviser and a Fidelity Investments company. Brokerage services provided by Fidelity Brokerage Services LLC, Member NYSE, SIPC, a Fidelity Investments company. Custody and other services provided by National Financial Services LLC, Member NYSE, SIPC, an affiliate of Strategic Advisers, Inc., and a Fidelity Investments company. 462185.3.0 U113-SCF-0909 1.808820.109 1.808820.109 Page 6 of 6 012160206