The Directed Account Plan Partial Withdrawal Request Form (Page 3 of 3) in pdf

The Directed Account Plan Partial Withdrawal Request Form Page 3

The Directed Account Plan

Partial Withdrawal

Rollover Form

Plan Number 21622

Participant Information:

Name:

SSN:

ROLLOVER INSTRUCTIONS:

Partial Distribution from the plan in the amount of

(The actual amount may vary

at the time of the distribution due to market fluctuations and/or changes in funds available.)

Of the amount, I want

% rolled over and the remainder paid out to me.

Please Note: The portion of your account you choose not to directly rollover may be subject to the automatic 20%

federal income tax withholding requirement. After-tax contributions to the qualified retirement plan are not eligible to

be rolled over to a retirement account, but may be transferred directly to a Fidelity non-retirement account.

DIRECT ROLLOVER TO A FIDELITY ROLLOVER IRA

Direct rollover to a Fidelity IRA.

(A Fidelity Rollover IRA account must be established in order to process the direct rollover.)

I understand that my balances in all mutual funds that are eligible for in-kind distribution will be transferred in-kind

to my Fidelity IRA. I understand that my balances in all other investment options, such as GIC funds,

commingled pools, and mutual funds that are not eligible for in-kind distribution will be liquidated and invested in

Fidelity Cash Reserves, a money market fund. Please note, the determination of which non-Fidelity funds are

eligible for in-kind distribution will be made as of the date the distribution is processed, and not as of the date the

transaction is initiated. Over time, Fidelity may be changing the non-Fidelity funds eligible for in-kind transfer

DIRECT ROLLOVER TO CUSTDIAN OTHER THAN FIDELITY:

Custodian:

Address:

TRANSFER OF AFTER TAX ASSETS AND/OR TAXABLE ASSETS NOT ROLLED OVER:

% Paid out to me*

Fidelity Investments Institutional Operations Company, Inc.

553461.1.0

The Directed Account Plan Partial Withdrawal Request Form Page 3