Use this form to request a one-time immediate distribution from a Fidelity Traditional, Rollover, SEP, Roth, or SIMPLE IRA. If you
wish to request a one-time distribution via check to your address of record, and you have not changed your record address in the
past fifteen days, you may also call us at 1-800-544-6666 to make this request over the phone, or visit Fidelity.com to make this request
online. Note: Any distributions greater than $100,000 must be requested in writing. If you are converting into a Roth IRA, requesting a
return of excess contribution, or taking a distribution due to a divorce, call us at 1-800-544-4774 between 8 a.m. and 8 p.m. Eastern
time for the appropriate form, or visit us at Fidelity.com. You may wish to consult with your tax advisor regarding the tax implications
associated with each distribution.
This form should not be used to request deposits into your bank or credit union account. To do this, you first need to request an
Electronic Funds Transfer (EFT), then you can make the deposit request over the phone or on Fidelity.com.
Return this completed form to the following address: Fidelity Investments, Attn.: Retirement Distributions, PO Box 770001, Cincinnati,
If sending your request by overnight delivery: Fidelity Investments, Attn.: Retirement Distributions, 100 Crosby Parkway, Mailzone KC1B,
Covington, KY 41015
When you withdraw the entire balance from your IRA, a closeout fee may apply. Back-end loads, redemption fees or transaction
fees may also apply to mutual fund distributions. Refer to the IRA Schedule of Fees and the fund’s prospectus for details.
1 REASON FOR WITHDRAWAL
Check the appropriate box to reflect the reason for your withdrawal request to ensure appropriate reporting for your IRA distribution.
Note that if you are under age 59½ and are taking distributions for a qualified first-time home purchase ($10,000 lifetime total), qualified
higher education expenses, certain medical expenses or health insurance premiums as defined in the Inter