Instructions: Use this form if you wish to request a distribution from your employer’s plan. Please complete steps
1 through 9 to avoid delays in processing your request. Return this form, unless otherwise directed, to:
Fidelity Investments , PO Box 770002, Cincinnati, OH 45277-0090.
If you wish to overnight your form, please send it to Fidelity Investments, 2300 Litton Lane KH1E, Hebron, KY 41048.
Questions: If you would like more information about distributions, including general tax implications, please call 1-800-343-0860
Monday through Friday from 8:00 A.M. to midnight ET.
STEP 1 PARTICIPANT INFORMATION
A. Your Information Please use a black pen and print clearly in CAPITAL LETTERS.
Check here if you made any changes to the pre-filled information below
Social Security #:
Date of Birth:
I understand my check and all future correspondence related to this account will be mailed to the address below. If your address below is different
than the address on your statement, your request will be held for 15 days unless you complete STEP 8
Address Line 2:
B. The employer sponsoring the plan from which you are requesting this distribution
The distribution may require an authorized signature by the employer sponsoring the plan. Please see STEP 9 for more details.
Name of Employer Sponsoring the Plan:
C. Applicable Accounts I would like a distribution from the following plan(s):
STEP 2 REASON FOR DISTRIBUTION
Please choose one: If you do not choose an option below, your distribution will be delayed.
Attainment of age 591/2
Separation from service
Disability (as defined by the IRS)
In-service withdrawal Check with your employer before selecting this option. Some plans do not allow in-service withdrawals
Financial hardship (Employer authorization is required) Reason for hardship:_______________________________