Close Fidelity Account Form

Authorization to Close Account Customer Information Name of Owner or Business/Trust Social Security or TIN Co-Owner or Trustee/Authorized Person Account Number to be closed Daytime Phone Use this form to authorize Fidelity to close your Fidelity Brokerage Account or Fidelity IRA. Complete the customer information section above. For non-retirement accounts complete sections one two four and five. For IRA accounts complete sections one three four and five. Return the completed form to Fidelity Investments Attn Distributions PO Box 770001 Cincinnati OH 45277-0035. Visit us at Fidelity. com or call us at 1-800-544-6666 to cancel any open orders or sell securities prior to submitting this form* ACCOUNT FEATURES Follow the steps below to ensure your account is properly closed Checkwriting Destroy all unused checks. If you have any Automatic Account checks outstanding on your account indicate Builder the check number and amount below Charge or Check Card Direct Deposit Please call us or visit Fidelity. com to cancel this feature. Cut in half and attach to this form* Notify your payroll department or government agency to discontinue the service. BillPay Visit our Web site or call to cancel payments. Pre-Authorized Debits Notify any third party you have authorized to debit your account. NON-RETIREMENT ACCOUNT SECURITIES Indicate below if you are transferring your securities to another Fidelity account or requesting shares be sent in certificate form* Transfer my our securities stocks bonds CDs mutual funds etc* to my our Fidelity Account Send individual eligible securities to my our address. IRA ACCOUNT TAX ELECTION AND DISTRIBUTION INSTRUCTIONS You may elect not to have Federal withholding apply provided you have supplied Fidelity with a U*S* address or you may elect to increase the rate of withholding. If left blank IRS regulations require us to withhold federal income tax at a rate of 10 from your total IRA distribution excluding Roth IRA distributions even if you have made non-deductible contributions to your IRA. This may result in excess withholding of your distribution* Federal income tax will not be withheld from a distribution from a Roth IRA unless you elect to have such tax withheld or are otherwise subject to withholding because you are a non-resident alien* Whether or not you elect to have withholding apply you are responsible for the full payment of federal income tax any state or local taxes and any penalties which may apply to your distribution* You may be responsible for estimated tax payments and could incur penalties if your estimated tax payments are not sufficient. Check one of the following to indicate whether you wish to have federal income tax withheld. If no box is checked Fidelity is required to withhold 10 from the gross distribution excluding Roth IRAs. I elect NOT to have federal taxes withheld. I want Fidelity to withhold federal taxes at the rate of specify a percentage between 10 99. Please continue 1. 746017. 104 009900001 continued Check the appropriate box to reflect the reason for your distribution to ensure appropriate reporting for your IRA distribution* Note that if you are under age 591 2 and are taking distribution for a qualified first-time home purchase 10 000 lifetime total qualified higher education expenses certain medical expenses or health insurance premiums as defined in the Internal Revenue Code Section 72 t mark the box for Early Distribution* Establishing or making changes to a Substantially Equal Periodic Payment Plan should be discussed with your tax advisor.