Fidelity Advisor 403(b) Distribution Request Form Instructions

Enter the full name of the account owner, including first name, middle initial, and last name, or the name of the trust, estate, or other non-trust fiduciary.

Provide the account owner's date of birth.

Enter the street address of the account owner.

Enter the apartment number, if applicable.

Enter the city of the account owner's address.

Enter the state of the account owner's address.

Enter the ZIP code or postal code of the account owner's address.

Enter the work telephone number of the account owner.

Enter the extension for the work telephone number, if applicable.

Enter the home telephone number of the account owner.

Enter the account owner's Social Security Number.

Provide the account owner's date of hire.

Check this box if you want to make a direct rollover distribution to an account held by another custodian or trustee.

Check this box if the receiving account for the direct rollover is an IRA.

Check this box if the receiving account for the direct rollover is a 403(b) plan.

Check this box if the receiving account for the direct rollover is an employer-sponsored, qualified 401(a) plan.

Check this box if the receiving account for the direct rollover is an eligible 457(b) plan maintained by a state governmental agency.

Check this box if you want to include designated Roth 403(b) amounts in the rollover to another custodian/trustee.

Please provide the full legal name of the receiving custodian or trustee.

Check this box if you wish to direct your rollover distribution to an existing 403(b) account or program at Fidelity.

Please provide the name of the existing 403(b) account at Fidelity that will receive the direct rollover distribution.

Check this box if you want the distribution to be made proportionally across all available investment options.

Check this box if you want the distribution to be made from specific sources or investment options, which you will then need to specify.

Please provide the full name of the financial advisor's firm.

Please provide the financial advisor's full name, including first name, middle initial, and last name.

Please enter the financial advisor's daytime telephone number.

Please provide the extension for the financial advisor's daytime telephone number.

Please enter the financial advisor's fax number.

Check this box if the first direct rollover funds originate from an employer account(s).

Check this box if the first direct rollover funds are from a pretax contribution source.

Check this box if the first direct rollover funds are from a Roth contribution source.

Check this box if the first direct rollover funds are from an after-tax contribution source.

Check this box if 100% of the funds for the first direct rollover should be taken from the specified source.

Enter the name of the fund for the first partial withdrawal source.

Enter the amount to be withdrawn from this source.

Please enter the name of the first investment fund for distribution.

Check this box if the first specific investment source for distribution is an Employer Account(s).

Check this box if the first specific investment source for distribution is a Pretax account.

Check this box if the first specific investment source for distribution is a Roth account.

Check this box if the first specific investment source for distribution is an After-Tax account.

Please enter the dollar amount to be distributed from this specific investment source.

Check this box if 100% of the distribution should come from this first specific investment source.

Check this box if you would like the full withdrawal payment to be deposited into a Fidelity Advisor Non-Retirement Account.

Provide the account number for the Fidelity Advisor Non-Retirement Account where the full withdrawal will be deposited.

Check this box if you would like the full withdrawal payment to be sent to you via check.

Check this box if you would like the check proceeds to be mailed to you, noting that a $25 fee will apply.

Check this box if you elect not to have federal income taxes withheld from your distribution.

Check this box if you elect not to have state income taxes withheld from your distribution, noting that some states may still require state income tax to be withheld.

Check this box if you have enclosed an IRS W-4P form to request that federal and state withholding be based on the elections/directions in this form, understanding that some states may not base withholding on the Form W-4P.

Enter the printed name of the shareholder or authorized signer.

Check this box if you want the partial withdrawal proceeds to be deposited into a Fidelity Advisor non-retirement account.

Enter the account number for the Fidelity Advisor non-retirement account where the partial withdrawal payment should be deposited.

Check this box if you want the partial withdrawal proceeds to be paid by check.

Check this box if you want the partial withdrawal check to be sent via express mail, acknowledging that a $25 fee will be assessed.

Check this box if you want the payment deposited into a Fidelity Advisor Non-Retirement Account.

Enter the account number for the 1st deposit into a Fidelity Advisor Non-Retirement Account.

Check this box if you want the payment to be delivered by check.

Check this box if you want the payment to be delivered via Electronic Funds Transfer (EFT).

Check this box if the reason for distribution is that you have attained the age of 59 and a half, and employer, plan sponsor, or TPA signature is not required.

Check this box if the reason for distribution is your separation from service or severance from employment with the employer.

Check this box if the reason for distribution is due to disability.

The user should check this box if they wish to roll over their entire account balance.

The user should check this box if they wish to roll over only a portion of their account balance.

Enter the name of the fund for the second direct rollover source.

Enter the amount for the second direct rollover source.

Enter the name of the fund for the second partial withdrawal source.

Check this box if the second partial withdrawal should be taken from employer account(s).

Check this box if the second partial withdrawal should be taken from pretax funds.

Check this box if the second partial withdrawal should be taken from Roth funds.

Check this box if the second partial withdrawal should be taken from after-tax funds.

Enter the amount to be withdrawn from this second partial withdrawal source.

Check this box to indicate that 100% of the funds from the specified source should be used for the second partial withdrawal.

Provide the name of the second specific investment fund from which distributions will be made.

Check this box if the second specific investment source for distribution is from an Employer Account(s).

Check this box if the second specific investment source for distribution is from a Pretax account.

Check this box if the second specific investment source for distribution is from a Roth account.

Check this box if the second specific investment source for distribution is from an After-Tax account.

Enter the dollar amount to be distributed from the second specific investment source.

Check this box if you want 100% of the distribution from this second specific investment source to be used.

Check this box to select the Specific Dollar Method as your periodic payment method for systematic withdrawals.

Enter the specific dollar amount to be paid each period.

Check this box if you want your Specific Dollar Method payments to be made monthly.

Check this box if you want your Specific Dollar Method payments to be made quarterly.

Check this box if you want your Specific Dollar Method payments to be made yearly.

Enter the date the payments should begin.

Check this box if you want payments for the Specific Period Method to be distributed monthly.

Check this box if you want payments for the Specific Period Method to be distributed quarterly.

Check this box if you want payments for the Specific Period Method to be distributed yearly.

Enter the number of years for which payments will be calculated.

Enter the starting year for the specified payment period.

Check this box if you would like your rollover to be directed to your Fidelity Advisor Traditional and/or Roth IRA in kind.

Enter the IRA account number for the Fidelity Advisor Traditional or Roth IRA to which the rollover will be directed.

Please enter the full legal name of the employer sponsoring your plan.

Please provide the telephone number of your employer.

Please enter the street address of your employer.

Please enter the suite or apartment number for your employer's address, if applicable.

Please enter the city where your employer is located.

Please enter the state where your employer is located.

Please enter the ZIP code or postal code for your employer's address.