One-Time Withdrawal – IRA, Fidelity Investments Completed Form Examples and Samples
Explore real-world examples and samples of the One-Time Withdrawal – IRA form from Fidelity Investments. See filled-out form examples covering early withdrawals, required minimum distributions, federal and state tax withholding elections, and various delivery methods to help you complete your own Fidelity IRA withdrawal request accurately.
Fidelity One-Time IRA Withdrawal Example – Early Withdrawal with Federal Tax Withholding
How this form was filled:
This example shows a 45-year-old account holder requesting a partial one-time withdrawal from a Traditional IRA at Fidelity Investments. The account owner elected a fixed dollar amount distribution, chose federal tax withholding at 20%, and selected direct deposit to a linked bank account as the delivery method. Because the owner is under 59½, this qualifies as an early distribution subject to a potential 10% IRS penalty.
Information used to fill out the document:
- Account Owner Full Name: Margaret L. Collins
- Social Security Number: ***-**-6712
- Date of Birth: 03/14/1980
- Primary Phone Number: 415-555-0192
- Email Address: [email protected]
- Account Number: 2389-4892
- Account Type: Traditional IRA
- Distribution Type: Early Distribution (Under Age 59½)
- Withdrawal Amount Type: Fixed Dollar Amount (Gross)
- Withdrawal Amount: $12,500.00
- Federal Income Tax Withholding: 20%
- State Income Tax Withholding: 5% (California)
- Delivery Method: Electronic Funds Transfer (EFT) – Direct Deposit
- Receiving Bank Name: Bank of America
- Bank Account Type: Checking
- Bank Routing Number: 026009593
- Bank Account Number: ****8841
- IRS Distribution Code: 1 – Early Distribution, no known exception
- Signature: Margaret L. Collins
- Date Signed: 01/22/2026
What this filled form sample shows:
- Correctly identified account type as Traditional IRA with matching account number
- Appropriate distribution type selected as Early Distribution (Under Age 59½) with IRS Code 1
- Fixed gross dollar amount of $12,500.00 specified for the one-time withdrawal
- Federal tax withholding elected at 20% to offset anticipated income tax liability
- State tax withholding elected at 5% for California residency compliance
- Direct deposit delivery method selected with linked Bank of America checking account
- Form properly signed and dated in January 2026 by the account owner
- Acknowledgment of potential 10% early withdrawal penalty for distributions before age 59½
Form specifications and details:
| Use Case: | Early partial one-time withdrawal from a Traditional IRA before age 59½ |
| Form Name: | One-Time Withdrawal – IRA |
| Issuing Institution: | Fidelity Investments |
| IRA Type: | Traditional IRA |
| Account Holder Age at Withdrawal: | 45 years old |
| Distribution Category: | Early Distribution |
| IRS Tax Form Generated: | 1099-R |
| IRS Distribution Code: | Code 1 – Early distribution, no known exception |
| Gross Withdrawal Amount: | $12,500.00 |
| Federal Withholding Rate: | 20% |
| State Withholding Rate: | 5% (California) |
| Estimated Net Distribution: | $9,375.00 |
| Delivery Method: | Electronic Funds Transfer (EFT) |
| Penalty Applicability: | 10% early withdrawal penalty may apply |
| Form Completion Date: | January 22, 2026 |
| Categories: | investment forms, IRA forms, withdrawal forms, Fidelity forms |
| Created: | February 25, 2026 04:39 AM |