Fidelity Life Ownership Change Request Form (Page 2 of 2) in pdf

Signatures:

By signing below, the Owner(s) hereby certify that the information provided in this request is complete and accurate, and understand that this request

will be processed according to the information provided. If there is any inconsistency between the language in this form and the policy, the policy

language will apply.

________________________________________

X_________________________________________

______________________

Name of Owner (current) (please print)

Owner’s Signature (current)

Date

(if corporate, trust or partnership owned, note title

of officer, trustee or partner, respectively)

________________________________________

X_________________________________________

______________________

Name of New Owner (please print)

New Owner’s Signature

Date

________________________________________

X_________________________________________

______________________

Name of Irrevocable Beneficiary (if any)

Irrevocable Beneficiary’s Signature (if any)

Date

** Spousal Consent for Community Property States: If the policy is a resident of AZ, CA, ID, LA, NV, NM, TX, WA or WI, spousal consent is

required unless the participant has no legal spouse. Please note, that without the spousal signature (if applicable), we will not be able to process the

request.

__________________________________________________

_______________________

Policy owner has no legal spouse

** Spousal Signature (if applicable)

Date

This form must be notarized or have a signature guarantee in order to be processed. Please complete one of the sections below.

Signature Guarantee Instructions

You may have your signature guaranteed by one of the following:

A commercial bank, savings bank or credit union

A trust company, or;

A member of the national securities exchange (brokerage firm)