Fidelity Roth IRA Conversion Form Instructions
Complete this form to authorize the conversion or reconversion of all or part of your existing Fidelity IRA to your existing Fidelity Roth IRA. For assistance with this form, or for additional forms, visit Fidelity’s Web site at Fidelity.com or call us at 1-800-544-2226. Return the completed form to: Fidelity Investments Attn: Distributions KC1B PO Box 770001 Cincinnati, OH 45277-0044 If using overnight mail, send to: Fidelity Investments Retirement Distributions KC1B 100 Crosby Parkway Covington, KY 41015-4325
IMPORTANT INFORMATION ABOUT CONVERTING Read your Fidelity Roth Individual Retirement Account Custodial Agreement and Disclosure Statement which contain necessary information for converting to a Fidelity Roth IRA. • To be eligible to convert, your modified adjusted gross income (AGI) cannot exceed $100,000 (not including the IRA conversion amount) in the year of the conversion. This applies to both single and joint tax filers. Married individuals filing separate tax returns are not eligible to convert to a Roth IRA unless they have lived apart from their spouse for the entire tax year. • Please note: Withholding taxes from a Roth IRA Conversion may make you ineligible for a Roth IRA Conversion, as amounts withheld from a Roth IRA Conversion are used in determining conversion AGI eligibility. • If you are under age 59 1⁄2, you will be subject to a 10% early withdrawal penalty on any amounts 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 contributions in order to properly complete your federal tax forms. • If you have Fidelity Automatic Account Builder,® you are responsible for making changes to this feature.
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FIDELITY ACCOUNT INFORMATION
Please provide your personal information as it should appear on your account.
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TYPE OF IRA YOU ARE CONVERTING
Indicate the type of IRA you are converting to a Fidelity Roth IRA. If you are converting more than one IRA, complete one form for each IRA you are converting. You may send us a photocopy of the conversion form; however, we need an original signature on each one. Please note: SIMPLE-IRA assets withdrawn in the two-year period beginning on the date you first participated in a SIMPLE-IRA plan maintained by your employer may NOT be converted to a Roth IRA.
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YOUR FIDELITY IRA TO BE CONVERTED
Complete this section to convert your Fidelity Traditional IRA, Rollover IRA, SEP-IRA, or SIMPLE-IRA to a Fidelity Roth IRA. Fidelity will waive the closeout fees for the Fidelity IRA(s) you are converting to a Fidelity Roth IRA.
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IMPORTANT TAX WITHHOLDING NOTICE FOR DISTRIBUTIONS FROM YOUR IRA
IRS regulations require the Custodian/Trustee of your distributing IRA to withhold federal income tax at the rate of 10% from your gross IRA distributions, unless you elect not to have withholding apply. You may elect not to have federal withholding apply (provided you have supplied Fidelity with a U.S. address). Each time you request a distribution, including a Roth IRA Conversion, you will be revoking any prior withholding election on any previous distribution. If left blank, IRS regulations require us to withhold federal income tax at a rate of 10% from your total IRA conversion. If your state of residence is CA, DE, IA, KS, MA, ME, NC, OK, OR or VT and federal income tax withholding is applied to your conversion, state income tax will also apply. State tax withholding will be based on your state’s minimum withholding requirement. You are still responsible for the full payment of federal income tax, any state or local taxes, and any penalties which may apply to your withdrawal(s). You may incur IRS penalties if you are under age 59 1⁄2. You may be responsible for payment of estimated taxes and you may incur penalties if estimated tax payments are not adequate, or if certain other requirements are not met. The tax withholding election you make will only apply to this conversion request. Any amounts withheld and not replaced into your Fidelity Roth IRA within 60 days may be subject to a 10% early withdrawal penalty if you are under age 59 1⁄2.
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SIGNATURE SECTION
Please sign and date.
Q UESTIONS ?
Visit Fidelity’s Web site at Fidelity.com
Or call a Fidelity Representative at 1-800-544-2226
Fidelity Brokerage Services LLC, Member NYSE, SIPC
Fidelity IRA Roth Conversion Form
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FIDELITY ACCOUNT INFORMATION
Middle Initial: Date of Birth: Phone Number.:
First Name: Last Name: Social Security Number:
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INDICATE THE TYPE OF IRA YOU ARE CONVERTING
Traditional IRA Rollover IRA SEP-IRA SIMPLE-IRA*
*SIMPLE accounts held for less than two years will not be converted
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CONVERSION INSTRUCTIONS
Account number of your Fidelity Roth IRA
Fidelity IRA you would like to convert to a Roth IRA
We will not convert your account until pending trades have settled.
If you do not have a Fidelity Roth IRA, please leave this area blank and attach a completed new account application for a Fidelity Roth IRA to this form.
If no selection is made below, Fidelity will convert all of the IRA assets in the referenced account(s). Convert all of my IRA assets OR Convert only a portion of my IRA assets. Please select “Entire Position” or provide a dollar amount or number of shares for each investment below. – OR – Dollar Amount – OR – Number of Shares
Name of Security or Fund
Entire Position
$ $ $
Please continue on a separate sheet if needed.
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FEDERAL TAX WITHHOLDING
I elect not to have federal taxes withheld Important State Tax withholding information: Fidelity Investments will withhold state tax at the time of conversion if you live in a mandatory state (California, Delaware, Iowa, Kansas, Maine, Massachusetts, North Carolina, Oklahoma, Oregon, and Vermont) and you elect to have federal taxes withheld.
Check this box to indicate that you wish not to have federal income taxes withheld. If this box is not checked, Fidelity is required to withhold 10% from the gross conversion amount. Any amounts withheld and not replaced into your Fidelity Roth IRA within 60 days may be subject to a 10% early withdrawal penalty if you are under 59½.
1.701389.126
006920001
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SIGNATURE
I authorize and request Fidelity Management Trust Company as custodian of my IRA specified above in Section 3 (or its agents or successors) to make the above requested distribution from my IRA and conversion contribution to my Fidelity Roth IRA. I hereby attest that for the year of the conversion, my adjusted income is $100,000 or less. I hereby agree to indemnify Fidelity Management Trust Company (its agents, affiliates, successors, and employees) from any and all liability in the event I fail to meet any of the IRS requirements. I understand that annual carrying fees apply on Limited Partnerships. For full conversions, any “good til cancelled” (GTC) orders for the IRA are cancelled. I understand that I may be subject to income taxes on the amount converted from my IRA to a Fidelity Roth IRA to the extent that the converted amount is includable in my income (i.e., any tax-deductible contributions, pretax contributions and any earnings). If I am over age 70½, I attest that I have satisfied (or will satisfy) the IRS minimum distribution requirements for the current year pursuant to Section 401(a)(9) of the Internal Revenue Code with respect to my IRA. SIGNATURE (Please be sure to sign in ink) Date
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465360
FBSI-CON-OSC-0607 1.701389.126
Attn: Distributions KC1B, PO Box 770001, Cincinnati, OH 45277-0044 Fidelity Brokerage Services LLC, Member NYSE, SIPC
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