Fidelity Distribution Form
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4Questions? 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
criteria for eligibility (see Section 3).
To change your address, call your plan sponsor or go to
• 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
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
.
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
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.
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