Distribution Financial Hardship Page 3
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46. 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 7.
provide any required
information.
Set up EFT to bank or credit union account:
Allow 13-16 business days (includes verification, set-up 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
Check
this account.
Check sent to mailing address
default if no choice indicated. Allow 7 business days.
This option not
available for PO Box
Check sent by UPS delivery
A fee of $25 will be deducted from your account. Allow 2 business days.
or foreign addresses.
7. 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
Date
Spouse Signature
mm dd yyyy
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.TEMDISTFH.104
026370203
Page 3 of 4
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