Fidelity Advisor IRA Distribution Request for Automatic Rollover Accounts Instructions
This form contains 39 fields organized into 15 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Account Owner Name | ||
| Account Owner First Name | Text |
Enter the first name of the account owner.
|
| Account Owner Middle Initial | Text |
Enter the middle initial of the account owner.
|
| Account Owner Last Name | Text |
Enter the last name of the account owner.
|
| Additional Withholding Amount | ||
| Additional Withholding Amount | Number |
Enter the additional dollar amount you would like to have withheld.
|
| Address | ||
| Street Address | Text |
Please enter the street address.
|
| Apartment | Text |
Please enter the apartment, unit, or suite number.
|
| City | Text |
Please enter the city.
|
| State | Text |
Please enter the state.
|
| Zip/Postal Code | Text |
Please enter the zip or postal code.
|
| Address Update Option | ||
| Update address based on above information | Checkbox |
Check this box if you want to update the address on your IRA account based on the address information provided in the 'Account Information' section of this form.
|
| Alternate Address | ||
| Alternate Address Line 1 | Text |
Provide the primary street address for the alternate address.
|
| Alternate Address Apartment/Suite | Text |
Provide the apartment, suite, unit, or building number for the alternate address.
|
| Alternate Address City | Text |
Provide the city for the alternate address.
|
| Alternate Address State | Text |
Provide the state for the alternate address.
|
| Alternate Address Zip/Postal Code | Text |
Provide the zip or postal code for the alternate address.
|
| Contact Information | ||
| Mobile Phone Number | Text |
Enter the mobile phone number to be used as your primary contact to verify and authorize transactions.
|
| Email Address | Text |
Enter the email address to be used to verify and authorize transactions.
|
| Distribution Instructions | ||
| Distribute to address of record | Checkbox |
Check this box if you want the distribution check to be mailed to the address of record indicated in Section 1.
|
| Overnight check proceeds | Checkbox |
Check this box if you want the distribution check to be sent via overnight delivery; a $20 fee will be assessed.
|
| Distribute to alternate address | Checkbox |
Check this box if you want the distribution check to be mailed to an alternate address.
|
| Federal Tax Withholding Election | ||
| Elect NOT to Withhold Federal Tax | Checkbox |
Check this box if you elect NOT to have federal income taxes withheld from your IRA distribution(s).
|
| Withhold Federal Tax at Specified Rate | Checkbox |
Check this box if you want Fidelity to withhold federal income taxes at a specific percentage rate between 1% and 100%.
|
| Federal Tax Withholding Percentage | Number |
Enter the whole number percentage between 1% and 100% for federal income tax withholding from your IRA distribution(s).
|
| General | ||
| Button | ||
| Reset | Button | |
| IRA Account Number | ||
| Existing Rollover IRA Account Number | Text |
Enter the existing rollover IRA account number.
|
| Page 4 | ||
| Printed Signer Name | Text |
Enter the printed full name of the account owner or authorized signer.
|
| Signature Date | Date |
Enter the date of the signature.
|
| Personal Identification | ||
| Social Security Number | Text |
Please enter your Social Security Number.
|
| Date of Birth | Date |
Please enter your date of birth.
|
| Reason for Distribution | ||
| RD_Distribution_A | CheckBox | |
| RD_Distribution_B | CheckBox | |
| RD_Distribution_C | CheckBox | |
| RD_Distribution_D | CheckBox | |
| Trustee of Employer Plan | Text |
Provide the name of the trustee of the employer plan to whom the distribution check should be made payable.
|
| Reason for Distribution for Roth IRA Accounts | ||
| Roth IRA Distribution (Code T) | Checkbox |
Check this box if you are 59½ years of age or older, or disabled, for a Roth IRA distribution.
|
| Roth IRA Early Distribution, no known exception (Code J) | Checkbox |
Check this box if you are under the age of 59½ and are not disabled, for an early Roth IRA distribution with no known exception.
|
| State Tax Withholding Election | ||
| State Tax Withholding - Elect Not To Withhold | Checkbox |
Check this box if you elect NOT to have state income taxes withheld from your IRA distribution(s), noting that this may not be applicable in all states.
|
| State Tax Withholding - Elect Minimum Withholding Rate | Checkbox |
Check this box if you elect to have state income taxes withheld from your IRA distribution(s) at the minimum withholding rate for your state of residence.
|