Distribution - Recurring Payments Form - Fidelity Investments

ADVERTISEMENT
Questions? Call 1-800-343-0860, business days from 8 AM to midnight Eastern Time.
Distribution — Recurring Payments
Use this form to set up automatic, recurring distributions from your 401(a), 401(k), 403(b) or 457(b) governmental employer plan. Fill in
by hand using CAPITAL letters and black ink, or on screen (if PDF). If you need more room for information, use a copy of the relevant page.
Helpful To Know
• You can only take a distribution if you meet one of the
• To validate your profile, go to netbenefits.com/profile.
criteria for eligibility (see Section 3).
To change your address, call your plan sponsor or go to
netbenefits.com/profile.
• Workplace retirement plan distributions may have
tax consequences. You may want to consult a tax or
• For most other types of distributions (such as hardship or
rollover) find the appropriate forms at fidelity.com/atwork.
financial professional.
• Recurring payments that continue for 10 years or
• Non-resident aliens must provide IRS form W-8BEN and a
longer are not eligible for roll over to an IRA or to
U.S. taxpayer ID number to claim any tax treaty benefits.
other retirement plans.
• Before you submit this form, be sure to find out whether
• To set up recurring distributions for more than one
your plan requires plan sponsor approval of distribution
retirement plan, use a separate form for each plan.
requests. If your plan does, and there is no plan sponsor
signature in Section 10, your request will be denied.
• To get your plan number(s), call your plan sponsor
(the employer that provides the plan) or go to
mysavingsatwork.com.
1. Account Owner / Participant
Name
Social Security or Taxpayer ID Number
Date of Birth
Evening Phone
Daytime Phone
mm – dd – yyyy
E-mail
Not married
Married
your spouse may need to sign this form. Ask your plan sponsor or Fidelity.
Address
If the address we have for you is correct, skip to Section 2.
Providing a new
Address
address may delay
your check unless you
get a signature guar­
City
State/Province
Zip/Postal Code
Country
antee (see Section 9).
2. Plan Involved
Name of Plan Sponsor
Plan Number
To get your plan num­
ber, go to mysavings
atwork.com or call your
plan sponsor.
3. Reason for Distribution
Required by federal tax law and your plan.
Former Employees
Check ONLy one.
Contact your plan
Separation from service
you no longer work for the plan sponsor.
sponsor to confirm
which reasons your
Current Employees
plan accepts and
Qualified by age
whether you qualify.
Age requirement varies by plan type. you must be at least 59½ (for 457(b), 70½).
Other
must be specified in your plan.
Form continues on next page.
3.TEMDISTAWP.104
026350201
Page 1 of 4
Questions? Call 1-800-343-0860, business days from 8 AM to midnight Eastern Time.
Distribution — Recurring Payments
Use this form to set up automatic, recurring distributions from your 401(a), 401(k), 403(b) or 457(b) governmental employer plan. Fill in
by hand using CAPITAL letters and black ink, or on screen (if PDF). If you need more room for information, use a copy of the relevant page.
Helpful To Know
• You can only take a distribution if you meet one of the
• To validate your profile, go to netbenefits.com/profile.
criteria for eligibility (see Section 3).
To change your address, call your plan sponsor or go to
netbenefits.com/profile.
• Workplace retirement plan distributions may have
tax consequences. You may want to consult a tax or
• For most other types of distributions (such as hardship or
rollover) find the appropriate forms at fidelity.com/atwork.
financial professional.
• Recurring payments that continue for 10 years or
• Non-resident aliens must provide IRS form W-8BEN and a
longer are not eligible for roll over to an IRA or to
U.S. taxpayer ID number to claim any tax treaty benefits.
other retirement plans.
• Before you submit this form, be sure to find out whether
• To set up recurring distributions for more than one
your plan requires plan sponsor approval of distribution
retirement plan, use a separate form for each plan.
requests. If your plan does, and there is no plan sponsor
signature in Section 10, your request will be denied.
• To get your plan number(s), call your plan sponsor
(the employer that provides the plan) or go to
mysavingsatwork.com.
1. Account Owner / Participant
Name
Social Security or Taxpayer ID Number
Date of Birth
Evening Phone
Daytime Phone
mm – dd – yyyy
E-mail
Not married
Married
your spouse may need to sign this form. Ask your plan sponsor or Fidelity.
Address
If the address we have for you is correct, skip to Section 2.
Providing a new
Address
address may delay
your check unless you
get a signature guar­
City
State/Province
Zip/Postal Code
Country
antee (see Section 9).
2. Plan Involved
Name of Plan Sponsor
Plan Number
To get your plan num­
ber, go to mysavings
atwork.com or call your
plan sponsor.
3. Reason for Distribution
Required by federal tax law and your plan.
Former Employees
Check ONLy one.
Contact your plan
Separation from service
you no longer work for the plan sponsor.
sponsor to confirm
which reasons your
Current Employees
plan accepts and
Qualified by age
whether you qualify.
Age requirement varies by plan type. you must be at least 59½ (for 457(b), 70½).
Other
must be specified in your plan.
Form continues on next page.
3.TEMDISTAWP.104
026350201
Page 1 of 4
4. Payment Calculation Method
Your available plan assets may be less than your plan value. Tax withholding may apply.
By Payment Amount
By Number of Payments
Choose one method,
and provide any
Distribute proportionally from all available
Distribute the following number of payments pro-
required information.
plan assets:
portionally from all available plan assets:
Payment Amount
Payments
$
5. Frequency of Payments
Check only one. Some
Date of FIRST Payment
mm – dd – yyyy
Payments will continue until available
Once a year
Once a month
plans may not allow all
plan assets are depleted or you tell
options. Contact Fidelity
Every 3 months
Twice a month
us in writing to stop them.
to confirm which options
are available to you.
6. Tax Withholding
If you are a U.S. person and your recurring payments will continue for 10 years or longer, we will withhold federal taxes based on your marital
status and the number of exemptions you indicate below. If you do not indicate a marital status, and none is on file with Fidelity, we will with-
hold at the rate for a married person with 3 exemptions.
If you are a U.S. person and your recurring payments will be completed within 10 years, we will withhold federal taxes at the rate of 20%,
unless you indicate a higher withholding rate below.
For non-resident aliens, the minimum federal mandatory withholding rate of 30% will apply, unless the prevailing tax treaty rate applies because
you have a valid IRS Form W-8BEN on file with Fidelity.
Each state sets its own withholding rates and requirements on taxable distributions. We apply these rates unless you, or state law, direct otherwise.
If you are under age 59½, a 10% early distribution tax penalty may apply.
For residents of CT, NY, NM, NJ, ND, PA and RI you must provide a dollar amount for state withholding if you would like it withheld ($10 mini-
mum), otherwise no amount will be withheld.
Note that the amount of tax withheld will be calculated on, and subtracted from, the amount of your distribution. Amounts withheld may
be less or more than what you actually owe in taxes. The withholding instructions you provide here will remain in effect for this account until
you give us new instructions.
Federal Withholding —
Federal Withholding —
Account’s legal /
Payments to Continue for 10 Years or Longer
Payments to Continue for Less Than 10 Years
residential address
determines which
Do NOT withhold federal taxes
Withhold federal taxes at the minimum rate of 20%
state’s tax rules apply.
Withhold federal taxes based on marital status and
Withhold federal taxes at the rate of:
number of exemptions
Note that if there is federal with­
must be greater than 20%. Note
Percentage
holding, certain states require that there also be state withholding.
that if there is federal withholding,
.0%
certain states require that there also
Add an additional dollar amount of:
be state withholding.
This dollar amount will be withheld
Amount ($10 minimum)
in addition to any amount calculated
State Withholding
$
based on your marital status and
number of exemptions.
Withhold state taxes at the applicable rate
Marital status
In addition to the applicable rate, withhold a
dollar amount of:
Single
Married
Withhold ($10 minimum)
Number of exemptions
$
Exemptions
Provide number (typically you plus the number
Residents of CT, NY, NM, NJ, ND, PA and RI ONLY.
of your dependants, but can be any number).
Withhold state taxes in the amount of:
Withhold ($10 minimum)
$
Do NOT withhold state taxes unless required by law
Form continues on next page.
3.TEMDISTAWP.104
026350202
Page 2 of 4
7. Delivery Method
Electronic Funds Transfer (EFT)
Choose ONLy one
delivery method and
EFT is already set up on account
Allow 3 business days. Skip to Section 8.
provide any required
information.
Set up EFT to bank or credit union account:
Allow 13­16 business days (includes verification, set­up and transaction processing).
Transaction timings start
from when your distribu­
Checking
Provide account information or attach voided check.
tion request is approved,
Savings
and are estimates,
Provide account information or attach deposit slip.
not guarantees.
Bank Routing Number Nine digits, starts 0, 1, 2, 3, or 4. Bank Name
Ask your bank for the
routing number.
Checking or Savings Account Number
Checking or Savings Account Owner Name
your name must be
exactly the same
on your plan and
this account.
Check
Check sent to mailing address
default if no choice indicated. Allow 7 business days.
Deposit
Allow 3 business days.
Deposit into Fidelity non-retirement account:
Account Number
8. Spouse’s Consent
Complete if you are married and if required by your plan.
The spouse’s signature MUST either be notarized or be witnessed by a plan representative. A signature guarantee is NOT a notary seal.
By signing below, you:
• Voluntarily consent to the distribution(s) indicated on this form, knowing that your spouse’s request is not valid without your consent.
• Acknowledge that you may be giving up your right to receive assets that would otherwise go to you upon your spouse’s death.
• Acknowledge that your spouse’s waiver of a qualified joint and survivor annuity, if applicable, is not valid without your consent.
• Agree that if the distribution described in this form is not pro cessed within 180 days of the date you sign this form, your consent expires.
• Acknowledge that you cannot take back your consent unless your spouse allows you to, and files a new form with Fidelity.
Print Spouse Name
Spouse Signature
Date
mm – dd – yyyy
Notarization or Plan Representative Witness
State of
, in the County of
, subscribed and sworn to before me by
(Notary only.)
the above-named individual who is personally known to me or who has produced
as identification, that the
foregoing statements were true and accurate and made of his/her own free act and deed, on
/
/
.
Print Notary / Plan Representative Name
NOTARY SEAL / STAMP
Notary / Plan Representative Signature
Date
mm dd yyyy
My commission expires
/
/
.
(Notary only.)
Form continues on next page.
3.TEMDISTAWP.104
026350203
Page 3 of 4
9. Signature and Date
Account owner / participant must sign and date.
By signing below, you:
• Authorize Fidelity to act on all instructions given on this form.
• Acknowledge that you have received the Special Tax Notice and,
if applicable, the Forms of Benefit Notice and the Notice of the
• Accept all terms and conditions described in this form.
Waiver of the Qualified Joint and Survivor Annuity.
• Certify that all information you provided is correct to the best of
your knowledge.
Print Participant Name
Participant Signature
Date
mm dd yyyy
If the retirement plan requires a signature from the plan sponsor in Section 10, you do not need a signature guarantee. If the retirement
plan does NOT require a plan sponsor signature, you will need a signature guarantee if either of two cases applies:
• Your distribution is more than $10,000, it is not being sent using EFT already set up on your account, you are providing a new address,
AND it’s important that your transaction not be delayed by 10 days.
• Your distribution is more than $100,000.
Signature Guarantee
You can get a signature guarantee from most banks, credit unions, and other financial institutions. A Medallion signature guarantee must
guarantee at least the amount of your loan. A notary seal/stamp is NOT a signature guarantee.
NOT a Medallion signature guarantee
SIGNATURE GUARANTEE
Complete if applicable.
Financial Institution Representative Name
Phone
Extension
Medallion Level Fidelity Use Only
10. Plan Sponsor Approval
Consult your plan sponsor or Fidelity to determine whether plan sponsor approval is required. You may need plan sponsor approval even if
you no longer work for the sponsor.
Participant’s Date of Hire
Separation Date If applicable
Employer-Source Vesting
mm – dd – yyyy
mm – dd – yyyy
%
By signing below, you:
• Acknowledge that the distribution as requested on this form is permitted by the employer’s plan.
• Certify that you are on record with Fidelity as being authorized to sign on behalf of the plan sponsor.
Print Plan Representative Name
Plan Representative Signature
Date
mm dd yyyy
Unless otherwise directed, deliver to:
Did you print and sign the form, and attach any necessary
Regular mail
Overnight mail
documents? Did ALL required individuals sign? Send the ENTIRE form
Fidelity Investments
Fidelity Investments
and any necessary documents to Fidelity.
PO Box 770002
100 Crosby Parkway KC1E
Questions? Go to fidelity.com/atwork or call 1-800-343-0860
Cincinnati, OH 45277-0090
Covington, KY 41015
(TTY, 1-800-259-9743), business days (except NYSE holidays) from
Fax 1-877-330-2476 (ONLY if your request doesn’t require
8 AM to midnight (ET).
a signature guarantee)
On this form, “Fidelity” means Fidelity Investments Institutional Operations Company, Inc.
584380.4.0 (08/2013)
3.TEMDISTAWP.104
026350204
Page 4 of 4

Download Distribution - Recurring Payments Form - Fidelity Investments

264 times
Rate
4.3(4.3 / 5) 18 votes
ADVERTISEMENT
Page of 4