1.932150.111 Page 4 of 5 006891004
5. Tax Withholding
Distributions from your non-Roth IRA are subject to federal and, where applicable, state income tax withholding unless you elect not to
have withholding apply below (if you are a U.S. citizen or other U.S. person). For nonperiodic payments, the default withholding rate is
10%. You can choose to have a different rate by entering a rate between 0% and 100% below. Generally, you can’t choose less than 10%
for payments to be delivered outside the United States and its possessions. If you made nondeductible contributions to your IRA, this may
result in excess withholding from your distributions. If you elect not to have withholding apply to your distributions or if you do not have
enough federal income tax withheld from your distribution, you may be responsible for payment of estimated tax. You may incur penalties
under the estimated tax rules if your withholding and estimated tax payments are not sufficient. See “State Tax Withholding — IRA
Withdrawals” at the end of this form.
Do NOT complete this section if you are a nonresident alien. Instead, the nonresident alien tax-withholding rate of 30% will apply.
Complete if you would like a rate of withholding that is different from this default withholding rate. You should review the General
Instructions and the Marginal Rate Tables contained in the IRS Form W-4R at Fidelity.com/W-4R for additional information, which you can
download for free. If you don’t have access to a computer, you may request a copy by calling Fidelity, or the IRS at 800-829-1040.
Federal
Do NOT withhold federal taxes.
Withhold federal taxes at the rate of:
Percentage
Whole numbers; no dollar amounts or
decimals. Note that if there is federal tax
withholding, certain states require that
there also be state tax withholding.
%
State
Do NOT withhold state taxes unless required by law.
Withhold state taxes at the applicable rate.
Withhold state taxes at the rate of:
Percentage
Whole numbers; no dollar amounts
or decimals.
%
6. Signature and Date Account owner must sign and date.
By signing below, you:
• Authorize and request the custodian for
the Fidelity IRA, Fidelity Management
Trust Company and its agents, affiliates,
employees or successor custodians
(Fidelity) to withdraw the amount indicated
in Section 3 of this form.
• Acknowledge that non-Roth IRA distribu-
tions will generally be taxed as ordinary
income and may be subject to a 10% early
withdrawal penalty if taken before age 59½.
• Acknowledge that distributions from a
Roth IRA that are attributable to earnings
may be taxed as ordinary income and may
be subject to a 10% early withdrawal pen-
alty unless certain conditions are met.
• Acknowledge that Fidelity is not respon-
sible for changes in the value of assets that
may occur during the distribution process.
• Acknowledge that distributions made from
any SIMPLE IRA prior to age 59½ and
within the first two years of participating
in an employer’s SIMPLE IRA plan may be
subject to a 25% penalty.
• Acknowledge that if taking Substantially
Equal Periodic Payments, it is your respon-
sibility to comply with the IRS rules, and
that Fidelity reports such distributions as
“Early Withdrawal — no known exception”
in accordance with IRS requirements.
• Indemnify Fidelity from any liability
in the event that you fail to meet any
IRS requirement.
• Confirm, if you are not a U.S. person,
that you have attached or have on file
with Fidelity IRS Form W-8BEN that
includes your U.S. or foreign tax identifica-
tion number.
• Have viewed, read, and understand the IRS
Instructions for Form W-4R.
• Certify that the address associated with this
account is current and up to date.
Customers requesting EFT:
• Authorize and request Fidelity to make EFT
distributions from the Fidelity IRA listed in
this form by initiating debit entries to the
account indicated in this form.
• Authorize and request the bank named in
Section 4 to accept debit entries initiated
by Fidelity in such account and to debit the
same account without responsibility for the
appropriateness or for the existence of any
further authorization.
Customers transferring assets to an HSA:
• Acknowledge that qualified HSA funding
distributions are not subject to the 10%
early withdrawal penalty when transferred
directly to an HSA.
Customers transferring to a Fidelity Profit
Sharing or Self-Employed 401(k) Retirement
Plan account:
• Acknowledge that you have obtained
Plan Administrator consent to roll over the
amount listed on this form into your Fidelity
Retirement Plan account.
Customers requesting trade processing:
• Authorize Fidelity to process trades on
your behalf.
• Acknowledge that you are delegating to
Fidelity the discretion to determine the
price and time at which certain securities
should be sold pursuant to your instructions
contained in this form.
• Acknowledge that trades may take up to
five business days to process once the
request is received and determined to be in
good order, and that your authorization shall
remain in effect during the entire period.
• Acknowledge that certain securities cannot
be sold through this form and may require
you to call a representative or go online to
process the trades.
For Connecticut Residents:
• Acknowledge that, as a resident of CT,
your distributions from retirement accounts
are subject to the highest marginal tax
rate. If you are exempt from state tax,
you have the option to elect out of state
tax withholding. Otherwise, penalties
may apply. The penalty for reporting false
information is a fine of not more than
$5,000, imprisonment for not more than
five years, or both.
• Confirm that your state tax withholding
election is true, complete, and correct.
Check one in each
column. IRA owner’s
legal/residential
address determines
which state’s tax
rules apply.
Signature and Date continues on next page.