One-Time Withdrawal — Defined Contribution Retirement Plan Instructions

Please provide the full legal name of the account owner.

Please provide the Fidelity account number associated with this withdrawal request.

Please provide the account owner's Social Security Number (SSN) or Taxpayer Identification Number (TIN).

Please provide the account owner's date of birth.

Please provide the primary phone number where the account owner can be reached for questions.

Provide the first line of additional details or instructions to be included with the wire transfer.

Provide the second line of additional details or instructions to be included with the wire transfer.

Enter the first line of the alternate mailing address.

Enter the city for the alternate mailing address.

Enter the state for the alternate mailing address.

Enter the ZIP code for the alternate mailing address.

Please provide the Routing or ABA number for the correspondent (intermediary) bank.

Please provide the full name of the correspondent (intermediary) bank.

Enter the Fidelity account number for the direct rollover or conversion.

Enter the Fidelity fund name or symbol for the direct rollover or conversion.

Check this box to initiate a direct rollover from a Fidelity Roth Self-Employed 401(k) to a Fidelity Roth IRA.

Check this box to initiate a direct rollover to a Fidelity Traditional IRA or Fidelity Rollover IRA.

Check this box to initiate a direct conversion to a Fidelity Roth IRA.

Check this box to initiate a direct rollover to a Fidelity Inherited IRA, ensuring the decedent is the same on both accounts.

Check this box to indicate a direct rollover or conversion of an eligible distribution into an established non-Fidelity account.

Check this box if you are performing a direct rollover from a Fidelity Roth Self-Employed 401(k) to a non-Fidelity Roth IRA.

Check this box if you are performing a direct rollover to a non-Fidelity Traditional IRA or Rollover IRA.

Check this box if you are performing a direct conversion to a non-Fidelity Roth IRA.

Check this box if you are performing a direct rollover to a non-Fidelity Inherited IRA, where the decedent must be the same on both accounts.

Enter the name of the trustee or custodian for the non-Fidelity account.

Enter the account number for the non-Fidelity account.

Check this box if you want to distribute all core cash and Fidelity money market funds from your brokerage account.

Check this box if you want to distribute only a specific amount of cash from your brokerage account, which you must specify in the accompanying 'Dollar Amount' field.

Enter the specific amount of cash to be distributed from your brokerage account.

Check this box if you want to distribute the entire value of your account in cash, which will require selling all eligible securities.

Check this box if you want to distribute the entire value of your account as shares (in kind), which requires distributing into a Fidelity account as mentioned in Section 4.

Enter the bank account number for the Electronic Funds Transfer (EFT).

Check this box if you do not want federal taxes to be withheld from your distribution.

Check this box if you want federal taxes to be withheld at a specific rate from your distribution.

Enter the percentage of federal taxes to withhold.

Check this box if you want to distribute funds into your Fidelity nonretirement account.

Enter the account number for the Fidelity nonretirement account where the distribution should be made.

Enter the fund name or symbol for the Fidelity nonretirement account, applicable only for Fidelity Mutual Fund accounts.

Check this box if you want to provide specific instructions for distributing only certain eligible securities and their respective amounts.

Check this box if you have indicated specific securities (by checking box 1) and wish to sell them and distribute the proceeds as cash.

Check this box if you have indicated specific securities (by checking box 1) and wish to distribute them as shares (in kind).

Provide the name or symbol of the security for the first distribution instruction.

Check this box if you want to distribute all shares of the specified security when distributing in kind (by checking box 3).

Check this box if you want to distribute only a specific number of shares of the specified security when distributing in kind (by checking box 3).

Enter the number of shares for the first distribution instruction.

Check this box if you want to distribute shares equivalent to a specific dollar amount of the specified security when distributing in kind (by checking box 3), applicable only for Fidelity Mutual Fund accounts.

Enter the dollar amount for the first distribution instruction.

Check this box if the recipient bank account is located outside of the United States.

Enter the SWIFT code for the international account.

Enter the name of the country where the international account is located.

Check this box to certify that you completed an IRR in your Roth Self-Employed 401(k), the distribution includes assets from that IRR, and your Plan Administrator is responsible for tax-reporting, acknowledging potential penalties for early distribution.

Enter the taxable amount of distribution.

Enter the total Roth contribution amount.

Enter the amount allocable to an IRR within 5 years.

Check this box if the plan participant's marital status is single.

Check this box if the plan participant's marital status is married.

Enter the printed full name of the plan administrator or executor.

Enter the printed full name of the plan participant or inherited account owner.

Enter the printed full name of the spouse.

Enter the full name of the individual or entity for whose benefit the distribution is intended.

Enter the first line of the payee's street address.

Enter the city of the payee's address.

Enter the state or province of the payee's address.

Enter the ZIP or postal code of the payee's address.

Enter the country of the payee's address.

Please enter the name of the plan.

Check this box if the plan is a Money Purchase plan.

Check this box if the plan is a Profit Sharing plan, including Self-Employed 401(k).

Check this box if the plan is a Roth Self-Employed 401(k) plan.

Check this box if you are AT LEAST 59½ at the time of distribution.

Check this box if you are younger than 59½ at the time of distribution and qualify under the Plan definition of "disability" as defined in Article 2.16 of the Defined Contribution Retirement Plan.

Check this box if the distribution is for qualified birth or adoption expenses made within the one-year period following the date of birth or legal adoption, up to $5,000 per child.

Check this box if the distribution is for a qualified disaster recovery made within the first 180 days after the incident, up to an aggregate of $22,000.

Check this box if the distribution is due to domestic abuse by a spouse or domestic partner, made within one year following the incident, up to $10,300 or 50% of account balance.

Check this box if you are on active duty with an armed service for more than 30 days and have the option to request a distribution of your employee deferrals.

Check this box if you are an active duty member of the Reserves or National Guard and can take elective deferrals beginning on the date of the order or call to active duty after 179 days of active service.

Check this box if you have separated from service.

Check this box if the distribution is due to the death of the plan participant.

Check this box if the distribution is due to plan termination.

Check this box if you are required to take a Required Minimum Distribution (RMD) and are requesting to do so with this form.

Enter the required minimum distribution amount.

Check this box if you want to sell the eligible securities and distribute the proceeds as cash for the second distribution instruction.

Check this box if you want to distribute the eligible securities as shares (in kind) for the second distribution instruction.

Enter the name or symbol of the security for the second distribution instruction.

Check this box if you want to distribute all eligible shares (in kind) for the second distribution instruction.

Check this box if you want to distribute only a specific number of eligible shares (in kind) for the second distribution instruction, which should be entered in the 'Number of Shares' field.

Enter the specific number of shares for the second distribution instruction.

Check this box if you want to distribute shares equivalent to a specific dollar amount for the second distribution instruction, applicable only to Fidelity Mutual Fund accounts, and the amount should be entered in the 'Dollar Amount' field.

Enter the specific dollar amount for the second distribution instruction.

Check this box if you do not want state taxes withheld, unless state law explicitly requires it.

Check this box if you want state taxes withheld at the standard rate applicable to your situation.

Check this box if you want to specify a particular percentage for state tax withholding.

Enter the percentage rate at which state taxes should be withheld, expressed as a whole number without dollar amounts or decimals.

Please enter the street address of the wire recipient.

Please enter the city of the wire recipient's address.

Please enter the state or province of the wire recipient's address.

Please enter the ZIP or postal code of the wire recipient's address.

Please enter the country of the wire recipient's address.

The routing or ABA number of the wire recipient's bank.

The name of the wire recipient's bank.

The account number of the wire recipient.

The name(s) of the wire recipient account owner(s).