One-Time Withdrawal – IRA, Fidelity Investments Instructions

Enter the full name of the account owner.

Provide the Fidelity IRA account number associated with this withdrawal.

Enter the Social Security Number or Taxpayer Identification Number of the account owner.

Provide the primary phone number where the account owner can be reached for questions regarding this withdrawal.

Enter the routing or ABA number of the correspondent (intermediary) bank.

Enter the name of the correspondent (intermediary) bank.

Check this box if you are requesting a direct rollover to a workplace retirement plan, a check paid to a payee other than the IRA owner, or a check mailed to an alternate address.

Enter the full name of the workplace retirement plan or other payee.

Provide the account number for the workplace retirement plan.

Specify the name or department this payment is for the benefit of or attention of.

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.

Select this option to distribute all core cash and Fidelity money market funds from your brokerage account.

Select this option to distribute a specific dollar amount of cash from your brokerage account, which must then be entered in the accompanying field.

Enter the specific dollar amount to be distributed.

Select this option to distribute the entire value of your account as cash, which requires selling all eligible securities.

Select this option to distribute the entire value of your account as shares, in kind.

Select this option to distribute only specific eligible securities and amounts, which must then be detailed in the provided table.

Check this box if you want to use Electronic Funds Transfer (EFT) to a bank or credit union account where EFT instructions are already in place and the distribution is cash only. This form cannot be used to set up new EFT instructions.

Check this box if you want to use Electronic Funds Transfer (EFT) to your own bank account, where the names on the bank account and the IRA are the same.

Check this box if you want to use Electronic Funds Transfer (EFT) to an account belonging to someone else, available for brokerage accounts only, where the names on the bank account and the IRA are different.

Check this box if you want a physical check to be mailed to the address of record; this is also the default option if no choice is indicated or if another selected choice cannot be processed.

Check this box if you want funds to be transferred via bank wire to a bank or credit union account in your name or someone else's, noting that this is for cash only and the bank may charge a fee for wire transfers.

Check this box if you want to distribute funds into a Fidelity nonretirement, investment-only retirement, Defined Contribution Retirement Plan account, or your own Fidelity HSA.

Enter the account number for the Fidelity nonretirement, investment-only retirement, or HSA account.

Enter the name or symbol of the Fidelity mutual fund for distributions to mutual fund accounts only.

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

Check this box if you do not want federal taxes withheld from your distributions.

Check this box if you want federal taxes withheld at a specific rate, which you will then need to specify.

Enter the percentage of federal tax to be withheld from the distribution.

Check this box if you want to sell the first specified eligible security and distribute the proceeds as cash.

Check this box if you want to distribute the first specified eligible security directly as shares, rather than selling them.

Check this box if you want to distribute all shares of the first specified eligible security.

Check this box if you want to distribute only a specific number of shares for the first specified eligible security.

Check this box if you want to distribute a specific dollar amount for the first specified eligible security, applicable only to Fidelity Mutual Fund accounts.

Check this box if the recipient's bank account is located outside of the United States, indicating an international wire transfer.

Enter the SWIFT Code for the international wire transfer.

Enter the name of the country where the recipient bank is located for the international wire transfer.

Check this box if the account holder is at least 59½ years old at the time of distribution.

Check this box if the account holder is younger than 59½ years old at the time of distribution, noting that an IRS early distribution penalty may apply and a distribution from a Roth IRA will be reported as an early distribution.

Check this box if the withdrawal is due to the death of the original IRA owner, applicable for inherited accounts only.

Check this box to initiate a direct rollover of funds to a workplace retirement plan, such as a 401(k).

Provide the name of the workplace retirement plan for a direct rollover.

Check this box if you want to sell the second eligible security and distribute the proceeds as cash.

Check this box if you want to distribute the second eligible security as shares (in kind).

Enter the security name or symbol for the second security you wish to distribute as shares in kind.

Check this box if you want to distribute all shares of the second eligible security.

Check this box if you want to distribute only a specific number of shares of the second eligible security, and enter the quantity in the 'Number of Shares' field.

Enter the number of shares for the second security you wish to distribute.

Check this box if you want to distribute a specific dollar amount from the second eligible security, applicable only to Fidelity Mutual Fund accounts, and enter the amount in the 'Dollar Amount' field.

Enter the dollar amount for the second security to be distributed from Fidelity Mutual Fund accounts.

Check this box if you do not want state taxes withheld from your distributions, unless state law mandates it.

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

Check this box if you want to specify a custom percentage for state tax withholding from your distributions.

Enter the whole number percentage of state taxes to withhold.

Enter the bank routing or ABA number for the wire recipient's bank.

Enter the full legal name of the wire recipient's bank.

Enter the account number for the wire recipient.

Enter the name(s) of the owner(s) of the wire recipient's account.

Enter the street address of the wire recipient. Note that a full address is required for international wires.

Enter the city of the wire recipient.

Enter the state or province of the wire recipient.

Enter the ZIP or postal code of the wire recipient.

Enter the country of the wire recipient.

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

Provide any further additional details or instructions for the wire transfer.