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Participant/Retiree Minimum Required Distribution Form

If you are taking a Minimum Required Distribution (MRD) from more than one plan, please complete a form for each plan. Questions? Call Fidelity Investments at 1-800-343-0860, Monday through Friday, 8 a.m. to midnight Eastern time, or visit


Please choose only one: Calculate MRD only (complete Sections 2, 3, 4, and 10) Calculate MRD and distribute payment on a systematic basis (complete all sections) Distribute payment only--no calculation required (complete all sections except Section 4)

2. gEnERal InFORMaTIOn

A. Participant Information. Please use a black pen and print clearly in CAPITAL LETTERS. Social Security #: First Name: Mailing Address: City: Daytime Phone: E-mail: B. Employer/Plan Sponsor Information. Name of Current Employer/Site/Division: City: Date you terminated employment with the Plan Sponsor (if applicable): State: Zip: Plan Number (if known): State: Evening Phone: Zip: Date of Birth: Last Name: Apt. No.:


This authorization shall apply to all accounts under the following plan currently held at Fidelity Investments (choose only one): 403(b) Plan Qualified Plan [401(a)/401(k)] 457(b) Governmental Employer 457(b) Nonprofit Employer


A. Determine Minimum Required Distribution for the following calendar year(s) (for participants who have delayed or missed payments): B. Method of Calculation: Unless you check one of the following boxes and provide your spouse's date of birth below, the MRD payment will be calculated using the Uniform Lifetime Table. My sole beneficiary is my spouse, and my spouse is more than 10 years younger than me. Spouse Date of Birth: My primary beneficiary is a trust and my spouse who is more than 10 years younger than me is the sole irrevocable primary beneficiary/ payee of the trust. The trust requires that my spouse receive at least annually an amount equal to or greater than the MRD payment (enter spouse date of birth above). Both of the above conditions apply and there is no other primary beneficiary.


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C. 403(b) Plans--December 31, 1986 Balances (Pre-1987 balances). To be completed by 403(b) Plan Participants Under Age 75. Participants who are under age 75 may exclude from their MRD calculation any amounts accumulated in the 403(b) plan as of December 31, 1986. If you are eligible, and if account balances as of December 31, 1986, were accounted for separately, please indicate below if you want your entire plan balance to be included in your MRD calculation or if you want to exclude your adjusted December 31, 1986, balance. Any amounts taken from this account, other than MRD payments, must reduce your December 31, 1986, 403(b) balance. This amount is called your adjusted December 31, 1986, balance. I am under age 75 as of December 31 of the calendar year in which I am taking an MRD from my post-December 31, 1986, balance and request that Fidelity Investments (check one): Use my entire 403(b) Plan balance, including amounts accrued prior to December 31, 1986 Exclude my adjusted December 31, 1986, 403(b) plan balance of $__________________________.


Your MRD will be taken proportionately across all available investment options and sources, Please choose the method of distribution in which you would like to receive your MRD payments (please check one and provide the required information): A. Systematic Withdrawal Plan--MRD If you requested an MRD for the previous calendar year (see 4A above), this payment will be sent to you in a lump sum within seven to 10 business days after the distribution has been processed. If you would like to specify a date for this payment, please list it directly below.

If you want MRDs for subsequent years to be paid under Fidelity's Systematic Withdrawal Plan, please indicate the payment schedule and starting date. Systematic withdrawal payments are generally payable on the 10th day of the month elected. If the day is a weekend or holiday, the payment is processed on the next business day. Systematic Withdrawal Payment Frequency (check one): Monthly Quarterly Annually

Systematic Withdrawal Beginning Date: Systematic Withdrawal Form of Payment (check one): Electronic Funds Transfer to bank--complete and attach the enclosed EFT application. (EFT requires a 10-day setup period prior to processing a distribution.) Direct deposit to a Fidelity Investments nonretirement account. (Your money will be available in five to seven business days from the date of distribution.) Fidelity Account Number:

(Note: To establish a new account, please attach an account application.) Check (You should receive your check in seven to 10 business days from the date of distribution.) B. Single Payment--MRD Please indicate single payment amount. This option is appropriate for those who calculate their own MRD: $ Check this box if the payment is for multiple 403(b) plans Form of Payment (check one): Direct deposit to a Fidelity Investments non-retirement account. (Your money will be available in 5­7 business days from the date of distribution.) Fidelity Account Number: , .

(Note: To establish a new account, please attach an account application.) Check (You should receive your check in seven to 10 business days from the date of distribution.) Check sent by an express delivery service (NOT available for Systematic Withdrawal Plan). I understand that a fee of not more than $35 will be deducted from my account. This check cannot be delivered to a PO Box. Express delivery is available in the U.S. and Canada. (You should receive your check in four to five business days from the date of distribution.)

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You cannot roll MRD payments to an IRA or another retirement plan. A. For qualified plans, 403(b) plans, and governmental 457(b) plans, if you do not make an election below, Fidelity Investments is required, under Internal Revenue Code Section 3405, to withhold federal income tax. This election may be changed at any time by providing Fidelity Investments with a new IRS Form W-4P. I elect not to have federal income tax and, if applicable, state income tax withheld from my minimum required distribution payments. I elect to have federal income tax and, if applicable, state income tax withheld from my minimum required distribution payments at the rates required by law. I understand that if I want to change the withholding rate, I must complete and sign the enclosed IRS Form W-4P, and file it with Fidelity Investments. I acknowledge that if I do not check one of the boxes above or if I do not attach a Form W-4P to this form, Fidelity Investments will withhold income taxes from any MRD distribution based on the withholding tables for a married person with three allowances. B. For 457(b) plans sponsored by nonprofit employers, withholding will be determined on the Wage Withholding Tables as required by Internal Revenue Code Section 3401 and the method you select below, unless you provide an IRS Form W-4. The withholding amount will be based solely on the MRD payments. If you do not check one of these boxes or provide a W-4, then the Single Tax Return rate from the Wage Withholding Table will apply. Single Tax Return, one exemption Joint Tax Return, two exemptions If you are a non-resident alien, you must submit IRS Form W-8BEN, Certificate of Foreign Status of Beneficial Owner for United States Tax Withholding, with this Distribution Request Form to claim tax treaty benefits, if applicable. Please note that a payment to a non-resident alien to an address outside the United States will be withheld at a 30% rate unless the payee submits a completed IRS Form W-8BEN. Please go to the IRS Web site,, to download the form. Please indicate your current marital status below. Single --I certify, under penalties of perjury, that I am not married as of the date this form is signed. I understand that if my plan is subject to ERISA or additional spousal consent requirements and I marry after this date but before distribution commences, the spousal consent rules for married individuals will apply to me. Married--I certify that I am married. I understand that if my plan is subject to ERISA or additional spousal consent requirements, my spouse must complete Section 8. If you are married and your plan requires spousal consent, then your spouse must sign the spousal consent portion in the presence of a notary public or a representative of the Plan. The spousal consent is valid until you change your distribution election.



The distribution requested on this form may require spousal consent. See Section 7 above. I hereby consent to the election of the distribution as indicated on this form. As the spouse of the Participant named in Section 2, I understand that, under the terms of the Plan, my spouse's retirement benefits are to be paid to me in the form of Qualified Joint and Survivor Annuity (QJSA) unless I choose to give up that right. By signing below, I hereby acknowledge that I understand: (1) that the effect of my consent may result in the forfeiture of benefits I would otherwise be entitled to receive upon my spouse's death; (2) that my spouse's waiver of the QJSA is not valid unless I consent to it; (3) that my consent is voluntary; (4) that my consent is irrevocable unless my spouse revokes the waiver to the QJSA; and (5) that my consent (signature) must be witnessed by a notary public or a representative of the Plan. Signature of Participant's Spouse: Date:


To be completed by a notary public or representative of the plan (if provided for under the terms of your employer's plan): Sworn before me this day In the State of Notary Public Signature: , County of


My Commission Expires: Notary stamp must be in the above box A signature guarantee cannot take the place of a notarized signature. The signature of an authorized representative of the plan below indicates verification of spousal consent only: Date:


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The distribution requested on this form may require the employer's approval. Check with the employer maintaining this plan or Fidelity Investments at 1-800-343-0860 to determine whether or not employer authorization is required. On behalf of (name of Participant): Signed: I approve the distribution described on this form. Date: Title:


Printed Name:


I hereby certify under penalties of perjury that my Social Security number in Section 2 of this form is correct. I understand that I may be responsible for payment of estimated tax and/or tax penalties to the IRS if my withholding and estimated tax payments are not sufficient. I certify that all information provided on this form is true and accurate. I am aware that Fidelity is basing the minimum required distribution calculation on information provided by me, and as such, Fidelity is not responsible for the calculations to the extent such calculations are based on assumptions or information that is incorrect or incomplete. Rather, Fidelity provides these calculations to me with the understanding that I will not hold Fidelity responsible in any way for these calculations, and that I will verify these calculations independently with my tax advisor or legal counsel. Your Signature:



A signature guarantee is required if plan sponsor approval of the distribution is not required (Section 9) and: · The amount of the distribution is $100,000 or more, or · The distribution is not sent to the address of record, or · Your address has changed within the last 15 days You may obtain a signature guarantee from a broker, dealer, municipal securities dealer, government securities broker, national securities exchange, registered securities association, clearing agency or savings association. Please inform the person providing the signature guarantee of the approximate amount of the distribution. Guarantees for less than the distribution amount will delay your request. If the guarantee stamp to the right is not a medallion signature, print the name of the person issuing the guarantee, their phone number and the amount of the signature guarantee: __________________________________________________________ __________________________________________________________ __________________________________________________________

For Fidelity Use Only Medallion Level

Place signature guarantee stamp in box.

Note: A notary public cannot provide a signature guarantee.

Unless otherwise instructed by your employer, return all the completed forms in the enclosed postage-paid envelope or mail to: Fidelity Investments P.O. Box 770002 Cincinnati, OH 45277-0090 or send overnight to: Fidelity Investments 100 Crosby Parkway, KC1E Covington, KY 41015

333484.4.0 Page 4

Fidelity Investments Institutional Operations Company, Inc.



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