Fidelity Investments Account Authority Form Instructions

Enter the full first and last name for Account Owner 1 as evidenced by a government-issued, unexpired document.

Enter the full first and last name for Account Owner 2 as evidenced by a government-issued, unexpired document.

Enter the full legal name of the associated company.

Enter the street address of the associated company.

Enter the city of the associated company's address.

Enter the state or province of the associated company's address.

Enter the ZIP or postal code of the associated company's address.

Enter the country of the associated company's address.

Check this box to grant limited authority to the agent named in the form for each account identified in Section 2; this will be the default if no other choice is indicated.

Check this box to grant full authority to the agent named in the form for each account identified in Section 2; note that granting full authority requires a Medallion signature guarantee in Section 7.

Enter the authorized agent's mobile phone number.

Enter the authorized agent's email address.

Enter the full name of the authorized agent to be removed from the account.

Provide the first name of the authorized agent as it appears on a government-issued, unexpired document.

Provide the middle name of the authorized agent as it appears on a government-issued, unexpired document.

Provide the last name of the authorized agent as it appears on a government-issued, unexpired document.

Please enter the authorized agent's Social Security or Individual Taxpayer Identification Number.

Please enter the authorized agent's date of birth.

Please enter the authorized agent's relationship to the account owner.

Check this box if you are a U.S. citizen.

Check this box if you are a foreign citizen.

Please enter the country of citizenship.

Check this box if you want duplicate account statements to be sent to the authorized agent.

Check this box if you want duplicate trade confirmations to be sent to the authorized agent.

Please enter your current occupation or job title.

Please provide the full name of your employer, or leave this field blank if you are self-employed.

Please enter the street number and street name of your employer's address.

Please enter the city where your employer is located.

Please enter the state or province where your employer is located.

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

Please enter the country where your employer is located.

Check this box if the person is currently employed.

Check this box if the person is currently self-employed.

Check this box if the person is retired.

Check this box if the person is not employed (and not retired or self-employed).

Check this box if you want to keep all currently existing authorized agents in place.

Check this box if you want to remove all existing authorized agents.

Check this box if you want to remove only a specific authorized agent, whose name you will provide.

Enter the name of the first affiliate's company.

Enter the trading symbol or CUSIP for the first affiliate's company.

Check this box if you are providing a passport number as your government identification.

Check this box if you are providing a permanent resident identifier as your government identification.

Check this box if you are providing an other government-issued ID number as your government identification.

Enter the identification number from your government-issued ID.

Provide the country that issued the government identification.

Enter the date when your government identification was issued.

Enter the date when your government identification will expire.

Enter the first account number to be included in this authorization.

Enter the second account number to be included in this authorization.

Enter the third account number to be included in this authorization.

Enter the fourth account number to be included in this authorization.

Enter the fifth account number to be included in this authorization.

Enter the sixth account number to be included in this authorization.

Enter the street address, including apartment, unit, or suite number, for the legal or residential address.

Enter the city for the legal or residential address.

Enter the state or province for the legal or residential address.

Enter the ZIP or postal code for the legal or residential address.

Enter the country for the legal or residential address.

Check this box if the mailing address is the same as the legal/residential address, otherwise provide different information below.

Enter the primary street address or PO box for the mailing address.

Enter the city for the mailing address.

Enter the state or province for the mailing address.

Enter the ZIP or postal code for the mailing address.

Enter the country for the mailing address.

Enter the full printed name of the authorized agent.

Enter the full printed name of the first account owner.

Enter the full printed name of the second account owner.

Enter the full printed name of the Plan Administrator or Employer.

Enter the name of the second affiliate's company.

Enter the trading symbol or CUSIP for the second affiliate.

Enter the specific source of income, such as pension, investments, or spouse's income.

Check this box if you are a permanent resident of the U.S.

Check this box if you are a nonpermanent resident of the U.S.

Check this box if you are not a resident of the U.S.