Fidelity Non Prototype Retirement Form – Fill Out and Use This PDF

•An Investment-Only Retirement Account provides an investment vehicle for qualified retirement plan assets. Fidelity does not provide plan document, trustee, recordkeeping, tax-withholding, or tax-reporting services for this type of account.

•Only plan trustees can request distributions from the account.

•If the Investment-Only Retirement Account is a pooled account, then the trustee must obtain a Medallion signature guarantee for any distribution method other than a check made payable to the employer’s retirement plan.

•It is your responsibility to ensure that your distributions comply with IRS rules and all plan requirements. You should consult your third-party administrator and/or tax advisor prior to taking a distribution to ensure that all applicable recordkeeping, tax-reporting, and tax-

withholding requirements associated with the requested withdrawal are met.

•If this form directs Fidelity to sell shares of any security, be aware that the timing of the transaction depends on when we receive this form, which is outside of your control. To better control the timing of the transaction, you should direct the sale of securities online or through a Fidelity representative. Note: Certain securities (such as options, certain fixed income securities, and thinly traded securities) may not be eligible to sell via this form, which may result in Fidelity not being able to process this withdrawal as requested.

•Any fees charged or expenses incurred in connection with your instructions will be assessed at the “rep-assisted” rates. Fees and expenses may be lower if you instead place your trades online. Please refer to the Schedule of Fees for more information.

This phone number may be used if we have

questions, but will not be used to update your

account information.

Name of Employer Plan

Name of Plan Participant If applicable

Cash Distributions from a Brokerage Investment-Only Retirement Account

•If you withdraw all assets from your source account, that account will remain open, unless you tell us otherwise by checking the box below.

•Once we receive this form in good order, you cannot cancel your distribution request.

If the amount you indicate is greater

than your core account balance, your request will be denied.

For any distribution that involves the sale of mutual fund shares (other than money market funds) or other

securities, skip to “All Other Types of Distributions.”

ALL core cash and Fidelity money market funds in your account. Skip to Section 3. Close your account.

ONLY the following amount of cash in your account:

Distribution Instructions continues on next page.

Sell and distribute as cash

Distribute as shares (in kind)

Security Name or Symbol

Sell and distribute as cash

Distribute as shares (in kind)

3. Distribution Method

Security Name or Symbol

Check the appropriate method(s) and provide all required information.

3a. Distribute into your Fidelity nonretirement account

Fidelity Nonretirement Account Number Fidelity Fund Name or Symbol Fidelity Mutual Fund accounts ONLY e.g., 2AB-123456

Account Owner Name

3b. Direct rollover/conversion into another retirement account held with Fidelity:

Fidelity IRA, Roth IRA, or Fidelity Retirement Plan, including Money Purchase, Profit Sharing, and SE401(k)

Fidelity Investment-Only Account (formerly known as a Non-Prototype account). NOTE: If the plan name, tax ID, and/or plan participant are different between the sending and receiving accounts, a Medallion signature guarantee is required.

Trustee/Custodian Name

Account Number

For Benefit Of/Attention

Address

City

State/Province

ZIP/Postal Code

Country

All bank wire requests MUST have a Medallion signature guarantee.

A notary seal/stamp is NOT a Medallion signature guarantee.

FULL address is required for international wires.

3d. Bank wire to a bank or credit union account (cash only): Ask your bank for its wire routing number. The bank may charge a fee for wire transfers.

Wire Recipient

Additional Details (if applicable) Instructions to be included with the wire transfer.

If the bank uses a correspondent bank,

provide the information here.

Correspondent bank information may not be required for all wires.

Indicate if the recipient bank is outside the United States.

Correspondent (Intermediary)

Correspondent Bank Routing/ABA Number Correspondent Bank Name

Account is OUTSIDE the United States:

3e. Check payable to the employer’s retirement plan, mailed to the address of record Default if no choice indicated or if we are unable to process your choice.

3f. Check mailed to a different payee or to an address other than your address of record

Payee Name

Address

Form continues on next page.

•Authorize Fidelity or its agents, affiliates, employees, or successors, to make the above withdrawal.

•Understand that you have the responsibility for ensuring that all plan requirements for distribution are met including all applicable recordkeeping, tax-reporting, and tax- withholding requirements associated with the requested withdrawal.

•Indemnify Fidelity, its agents, affiliates, employees, and successors from any liability

associated with the distributions made on behalf of this retirement plan.

Customers requesting trade processing:

•Authorize Fidelity to process trades on your behalf.

•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.

PRINT TRUSTEE NAME

MEDALLION SIGNATURE GUARANTEE

Did you sign the form? Send the ENTIRE form to Fidelity Investments.

Questions? Go to Fidelity.com/smallbusiness or call 800-343-3548.