BOSTON/xinet/BosWork/Jobs/25543/PIECE95/25543 08 FRM OneTime WD FIDELITY 1010 Withdrawals Ira One Time
User Manual: FIDELITY 1010
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Print Reset Save Questions? Go to Fidelity.com/movemoney or call 800-343-3548. One-Time Withdrawal – IRA Use this form to make a one-time, tax-reportable distribution from a Traditional, Rollover, Roth, SEP, SIMPLE, or Inherited IRA. Do NOT use this form for Fidelity Retirement Plan accounts, annuities, nonretirement accounts, or for any IRA-to-IRA transfer. Also, do NOT use this form to purchase an investment in your IRA. Go to Fidelity.com/forms to find the appropriate form. Type on screen or fill in using CAPITAL letters and black ink. If you need more room for information or signatures, make a copy of the relevant page. Helpful to Know • It is your responsibility to ensure that your IRA distributions comply with IRS rules. All transactions made using this form are reported to the IRS as an IRA distribution. You may want to consult a tax advisor as such distribution generally results in taxable income to you. • Nonresident aliens must provide IRS form W-8BEN and a U.S. or foreign tax identification number. • If you are making withdrawals from more than one IRA, you must complete a separate form for each account. • For mutual funds, note that: –W ithdrawals could trigger redemption or transaction fees (see the applicable fund prospectus). – If a fund is closed to new investors, you will not be able to purchase new shares of the fund in the future if you draw your fund balance down to zero. • Drawing your total IRA balance down to zero could trigger account-closing fees. •A ll sales initiated by this form are charged at rep-assisted processing commission levels. If you want online commissions, please place the trade online and then distribute from cash in Section 3. 1. Account Owner Name Phone number may be used if we have questions, but will not be used to update your account information. Social Security or Taxpayer ID Number Fidelity IRA Account Number Daytime Phone Extension 2. Request Reason Check ONLY one. If directing your distribution to an HSA as a qualified HSA funding distribution, check either “Normal” or “Early distribution,“ as appropriate. Normal You are AT LEAST 59½ at the time of distribution. Early distribution You are younger than 59½ at the time of distribution. An IRS early distribution penalty may apply. Note: A distribution from a Roth IRA will be reported as an early distribution. Death of original IRA owner For inherited accounts only. Direct rollover to a workplace retirement plan, such as a 401(k): Plan Name 3. Distribution Amount If this form directs Fidelity to sell shares of any securities (including mutual funds), be aware that you cannot control the timing of when your securities are sold, nor can you cancel or suspend your order once we have received and accepted this form. If you want to better control the timing of your liquidating transaction, you should direct the sale of securities online or through a Fidelity representative before submitting this form. If you withdraw all assets from your source account, that account will be closed. Cash Distributions from a Brokerage IRA For any distribution that involves the sale of mutual fund shares (other than money market funds) or other securities, Types of Distributions.” If the amount you indicate is greater than your core account balance, your request will be denied. ALL core cash and Fidelity money market funds in your brokerage account skip to “All Other Skip to Section 4. ONLY the following amount of cash in your brokerage account: Dollar Amount $ Skip to Section 4. Distribution Amount continues on next page. 1.932150.105 Page 1 of 4 006890701 3. Distribution Amount, continued All Other Types of Distributions If distributing shares in kind, you MUST check “Distribute to a Fidelity nonretirement account or Fidelity HSA” in Section 4. ENTIRE VALUE of your account in cash (all securities will be sold) ENTIRE VALUE of your account as shares (in kind) ONLY the following securities and amounts: Sell and distribute as cash Security Name or Symbol Distribute as shares (in kind) ALL shares Sell and distribute as cash ONLY this many shares: Number of Shares Dollar Amount ONLY this dollar amount: $ Fidelity Mutual Fund accounts only. Security Name or Symbol Distribute as shares (in kind) ALL shares ONLY this many shares: Number of Shares Dollar Amount ONLY this dollar amount: $ Fidelity Mutual Fund accounts only. 4. Distribution Method You must obtain a Medallion signature guarantee in Section 6 if requesting a bank wire, if sending a check to a payee other than the IRA owner or alternate address, if the requested payment amount is over $100,000, or if the address on the account has been changed within the past 10 days. Check one and provide all required information. irect rollover to a workplace retirement plan, check paid to a payee other than the IRA owner, or check D mailed to an alternate address: Workplace Retirement Plan or Other Payee Name Workplace Retirement Plan Account Number For Benefit Of/Attention Address City State/Province ZIP/Postal Code Country Bank wire to a bank or credit union account in your name or someone else’s (cash only): Ask the bank for its wire routing number. Fidelity or the bank may charge a fee for wire transfers. Wire Recipient All bank wire requests MUST have a Medallion signature guarantee. A notary seal/stamp is NOT a Medallion signature guarantee. Bank Routing /ABA Number Bank Name Account Number Account Owner Name(s) Required Address of Wire Recipient FULL address is required for international wires. City State/Province ZIP/Postal Code Country For Further Credit/Additional Details (if applicable) Instructions to be included with the wire transfer. Distribution Method continues on next page. 1.932150.105 Page 2 of 4 006890702 4. Distribution Method, continued 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 A ccount is OUTSIDE the United States: SWIFT Code Name of Country E lectronic funds transfer (EFT) to a bank or credit union account using EFT instructions already in place on the account (cash only). This form cannot be used to set up EFT. To add EFT to an account, go to Fidelity.com/eft or complete the Electronic Funds Transfer (EFT) Authorization form. A . EFT to your bank account. The names on the bank account and the IRA are the same. Provide bank information ONLY if there are multiple EFT instructions on the account identified in Section 1. B . EFT to someone else. (Available for brokerage accounts only.) The names on the bank account and the IRA are different. If EFT has not been established prior to the receipt of this request, a check will be mailed to the address of record. Bank Account Number D istribute into a Fidelity nonretirement account or Fidelity HSA: Requires Medallion signature guarantee if going to an account of which you are not an owner. Fidelity Nonretirement or HSA Account Number Fidelity Fund Name or Symbol Mutual fund accounts ONLY C heck mailed to the address of record Default if no choice indicated or if we are unable to process your choice. 5. 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 withholding 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. Do NOT complete this section if you are a nonresident alien. Instead, the nonresident alien tax-withholding rate of 30% will apply. State Federal Check one in each column. IRA owner’s legal/residential address determines which state’s tax rules apply. Do NOT withhold federal taxes. Do NOT withhold state taxes unless required by law. 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. Withhold state taxes at the applicable rate. Withhold state taxes at the rate of: Percentage % Maximum 99%. Whole numbers; no dollar amounts. Form continues on next page. 1.932150.105 Page 3 of 4 006890703 6. Signature and Date Account owner must sign and date. By signing below, you: • 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 withdraw the amount indicated in Section 3 of this form. •A cknowledge that non-Roth IRA distributions will generally be taxed as ordinary income, and may be subject to a 10% early withdrawal penalty if taken before age 59½. • Acknowledge that distributions from a Roth IRA that are attributable to earnings may be taxed as ordinary income and may be subject to a 10% early withdrawal penalty unless certain conditions are met. • Acknowledge that Fidelity is not responsible for changes in the value of assets that may occur during the distribution process. •A cknowledge that distributions made from any SIMPLE IRA prior to age 59½ and within the first two years of participating in an employer’s SIMPLE IRA plan may be subject to a 25% penalty. • Acknowledge that if taking Substantially Equal Periodic Payments, it is your responsibility to comply with the IRS rules, and that Fidelity reports such distributions as “Early Withdrawal — no known exception” in accordance with IRS requirements. • Indemnify Fidelity from any liability in the event that you fail to meet any IRS requirement. • Confirm, if you are not a U.S. person, that you have attached or have on file with Fidelity IRS Form W-8BEN that includes your U.S. or foreign tax identification number. Customers requesting EFT: • Authorize and request Fidelity to make EFT distributions from the Fidelity IRA listed in this form by initiating debit entries to the account indicated in this form. • Authorize and request the bank named in Section 4 to accept debit entries initiated by Fidelity in such account and to debit the same account without responsibility for the appropriateness or for the existence of any further authorization. Customers transferring assets to an HSA: • Acknowledge that qualified HSA funding distributions are not subject to the 10% early withdrawal penalty when transferred directly to an HSA. A Medallion signature guarantee is required: • to send a check to an alternate address or payee. • to request a bank wire. • if the address on the account has been changed within the past 10 days. • if the withdrawal is going to a Fidelity account with no common owner. • if the transaction is greater than $100,000. If the form is completed at a Fidelity Investor Center, the Medallion signature guarantee is not required. You can get a Medallion signature guarantee from most banks, credit unions, and other financial institutions. A notary seal/stamp is NOT a Medallion signature guarantee. MEDALLION SIGNATURE GUARANTEE PRINT OWNER NAME SIGN OWNER SIGNATURE X D AT E DATE MM/DD/YYYY X Did you sign the form? Send the ENTIRE form to Fidelity Investments. Questions? Go to Fidelity.com/movemoney or call 800-343-3548. Use the postage-paid envelope, drop off at a Fidelity Investor Center, OR deliver to: Regular mail Overnight mail Fidelity Investments Fidelity Investments Attn: Retirement Distributions Attn: Retirement Distributions P.O. Box 770001 100 Crosby Parkway KC1B Cincinnati, OH 45277-0035 Covington, KY 41015 On this form, “Fidelity” means Fidelity Brokerage Services LLC and its affiliates. Brokerage services are provided by Fidelity Brokerage Services LLC, Member NYSE, SIPC. 592522.6.0 (10/17) 1.932150.105 Page 4 of 4 006890704 State Tax Withholding — IRA Withdrawals Helpful to Know •E ach state sets its own withholding rates and requirements 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. •Y ou are responsible for paying your federal, state, and local income taxes and any penalties, including penalties for insufficient withholding. • Withholding taxes for Roth IRA distributions is optional. 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. 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. MI •M I generally requires 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 MI requirements governing pension and retirement benefits. Please reference the MI W-4P Form for additional information about calculating the amount to withhold from your distribution. • If you are subject to MI 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 MI requirements. 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 •S tate 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 •S C 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 (any whole number between 1% and 99%). All other states (and DC if not taking a full distribution) •S tate tax withholding is voluntary and you can choose the rate you want (any whole number between 1% and 99%). 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 652041.4.0 (11/14) 1.964543.103 Page 1 of 1
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xmp.iid:D33C75FA33206811808391878013653D, xmp.iid:03801174072068118C14F8D27997D8E0, xmp.iid:06801174072068118C14F8D27997D8E0, xmp.iid:09801174072068118C14F8D27997D8E0, xmp.iid:F5F7A86D0A2068118C14F8D27997D8E0, xmp.iid:F8F7A86D0A2068118C14F8D27997D8E0, xmp.iid:FBF7A86D0A2068118C14F8D27997D8E0, xmp.iid:FEF7A86D0A2068118C14F8D27997D8E0, xmp.iid:96C82A420C2068118C14F8D27997D8E0, xmp.iid:99C82A420C2068118C14F8D27997D8E0, xmp.iid:9CC82A420C2068118C14F8D27997D8E0, xmp.iid:255742C10D2068118C14F8D27997D8E0, xmp.iid:FDB1B7620E2068118C14F8D27997D8E0, xmp.iid:9145920B102068118C14F8D27997D8E0, xmp.iid:FC7F1174072068118C1487DC284CFB91, xmp.iid:FF7F1174072068118C1487DC284CFB91, xmp.iid:153521D40A2068118C1487DC284CFB91, xmp.iid:04801174072068118C14C966323F0263, xmp.iid:07801174072068118C14C966323F0263, xmp.iid:0A801174072068118C14C966323F0263, xmp.iid:C4E60AD4092068118C14C966323F0263, xmp.iid:C7E60AD4092068118C14C966323F0263, xmp.iid:01801174072068118083F53CD1EC8060, xmp.iid:04801174072068118083F53CD1EC8060, xmp.iid:07801174072068118083F53CD1EC8060, xmp.iid:6247EBEC3A2068118083A65397B14AA8, xmp.iid:6547EBEC3A2068118083A65397B14AA8, xmp.iid:6847EBEC3A2068118083A65397B14AA8, xmp.iid:A34D328A1B2068118083C6A75DEE653C History When : 2011:05:02 11:42:15-04:00, 2011:05:02 11:42:15-04:00, 2011:05:02 11:48:21-04:00, 2011:05:02 11:48:40-04:00, 2011:05:04 12:40:41-04:00, 2011:05:04 12:40:41-04:00, 2011:05:04 13:09:19-04:00, 2011:05:04 13:10:55-04:00, 2011:05:04 13:15:47-04:00, 2011:05:04 13:17:53-04:00, 2011:05:04 13:18:41-04:00, 2011:05:19 10:41:35-04:00, 2011:05:19 10:41:35-04:00, 2011:05:19 10:44:11-04:00, 2011:05:19 12:31:45-04:00, 2011:05:19 12:37:50-04:00, 2011:05:19 12:39:28-04:00, 2011:05:19 12:53:48-04:00, 2011:05:19 13:00:41-04:00, 2011:06:14 14:53:54-04:00, 2011:06:14 14:53:54-04:00, 2011:06:14 15:23:14-04:00, 2011:06:14 15:28:07-04:00, 2011:06:14 15:29:16-04:00, 2011:06:14 15:29:57-04:00, 2011:06:14 15:31:27-04:00, 2011:06:14 15:33:41-04:00, 2011:06:14 15:34:03-04:00, 2011:06:14 15:36:28-04:00, 2011:06:16 10:56:29-04:00, 2011:06:16 10:56:29-04:00, 2011:06:16 10:59:19-04:00, 2011:06:16 11:11:49-04:00, 2011:06:16 11:12:25-04:00, 2011:06:16 11:16:29-04:00, 2011:06:16 11:32:20-04:00, 2011:06:16 11:33:34-04:00, 2011:06:16 11:43:40-04:00, 2011:06:16 11:45:44-04:00, 2011:06:27 15:03:39-04:00, 2011:06:27 15:14:23-04:00, 2011:06:27 15:29:02-04:00, 2011:06:27 15:30:28-04:00, 2011:06:27 15:49:21-04:00, 2011:06:27 15:50:37-04:00, 2011:06:27 15:52:16-04:00, 2011:06:27 16:34:15-04:00, 2011:06:27 16:51:10-04:00, 2011:06:27 17:05-04:00, 2011:06:27 17:08:58-04:00, 2011:06:27 17:18:56-04:00, 2011:06:27 17:20:04-04:00, 2011:06:27 21:44:35-04:00, 2011:06:27 21:44:55-04:00, 2011:06:27 21:47:15-04:00, 2011:06:27 21:48:55-04:00, 2011:06:28 09:55:47-04:00, 2011:06:28 09:59:35-04:00, 2011:06:28 09:59:54-04:00, 2011:06:28 10:02:42-04:00, 2011:06:28 10:08:15-04:00, 2011:06:28 11:54:38-04:00, 2011:06:28 13:06:53-04:00, 2011:06:28 13:18:04-04:00, 2011:06:28 13:18:48-04:00, 2011:06:28 13:31:40-04:00, 2011:06:28 13:33:47-04:00, 2011:06:28 17:20:41-04:00, 2011:06:28 17:23:17-04:00, 2011:06:28 17:26:39-04:00, 2011:06:28 17:28:03-04:00, 2011:06:28 17:48:33-04:00, 2011:06:28 17:50:47-04:00, 2011:06:28 17:57:48-04:00, 2011:06:28 18:14:50-04:00, 2011:06:28 18:14:58-04:00, 2011:06:28 18:34:47-04:00, 2011:06:28 18:35-04:00, 2011:06:28 18:51:04-04:00, 2011:06:28 18:54:10-04:00, 2011:06:28 18:54:38-04:00, 2011:06:28 18:55:24-04:00, 2011:06:28 18:55:30-04:00, 2011:06:28 19:04:04-04:00, 2011:06:28 19:10:47-04:00, 2011:06:28 19:13:21-04:00, 2011:06:28 19:15:10-04:00, 2011:06:29 09:53:06-04:00, 2011:06:29 09:56:30-04:00, 2011:06:29 12:47:27-04:00, 2011:06:29 12:47:55-04:00, 2011:06:29 12:47:55-04:00, 2011:06:29 13:17:45-04:00, 2011:06:29 13:20:47-04:00, 2011:06:29 15:25:18-04:00, 2011:06:29 15:25:18-04:00, 2011:06:29 15:50:10-04:00, 2011:06:29 15:59:32-04:00, 2011:06:29 16:12:44-04:00, 2011:06:29 16:14:14-04:00, 2011:06:29 18:09:38-04:00, 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