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Fidelity Personal Retirement Annuity ®
Trustee Statement and Agreement Form
Use this form to establish a trust as the Owner and Beneficiary or to change the trustee(s) only on a Fidelity Personal Retirement Annuity contract.
This Statement voids all previous Trustee Statements filed with the Company.* If you have questions when filling out this form, please call us at
800-634-9361, Monday through Friday, 8 a.m. to 8 p.m. Eastern time. Faxes are not accepted.
NOTE: Not all annuity contracts owned by a trust will qualify for tax deferral. A contract will not qualify for tax deferral unless the trust holds the
contract as “an agent for a natural person” (Internal Revenue Code 72(u)(1)). We will not issue an annuity contract or change the ownership to a
trust unless all trustees agree to the terms below by providing their signatures in Section 5.
1 TRuST InFoRmATIon
Full Name of Trust
Trust Legal Address
City State ZIP
2 AcknowledgemenT
-
Tax Identification Number
Trust Mailing Address (if different from legal)
- -
Date of Trust Agreement
City State ZIP
I hereby certify that this new annuity application or existing annuity contract number will be held under one of
the following circumstances.
Please check one of the following:
A Revocable Living (Grantor) Trust, with a Grantor as the Lifetime Beneficiary of the Trust, and a Grantor registered as an Annuitant.
A Charitable Remainder Trust
I (We) do hereby represent that the trust will hold the annuity contract “as an agent for a natural person” in accordance with the provisions of
72(u)(1) of the Internal Revenue Code of 1986, as amended. The trust will be the Owner and also the Beneficiary of the annuity contract,
unless otherwise designated.
3 TRuSTee(S) InFoRmATIon
If there are more than two trustees either make a copy of Section 3 and have all trustees sign Section 5, or attach a separate piece of paper with their
names and required information from this section, along with the signature of each trustee.
Trustee #1 Name Trustee #2 Name
- -
- -
- -
Date of Birth
Social Security Number
Date of Birth
Address
City State ZIP
- -
Phone Number
Address
Phone Number
- -
- -
Social Security Number
City State ZIP
* “The Company” refers to Fidelity Investments Life Insurance Company, or in NY, Empire Fidelity Investments Life Insurance Company, ® New York, NY.
027810001

4 Add oR Remove A TRuSTee (Complete this section only if adding or removing a trustee from an existing trust.)
X
Adding a co-trustee
I (We), (name of co-trustee), certify that I am
(we are) the co-trustee of the above-named trust in accordance with the terms of the trust instrument.
Removing a trustee
Death of trustee. (name of deceased trustee)
Resignation of trustee. I (name of resigning trustee),
certify that I am resigning as trustee of the above-named trust.
SIGNATURE OF RESIGNING TRUSTEE DATE
5 TRuSTee(S) SIgnATuRe(S)
The undersigned trustee(s) certify(ies) that it/he/she is a trustee of the named trust in Section 1 of this form and that it/he/she is authorized to
exercise ownership rights under the contract in accordance with the terms of the trust. The trustee(s) agrees that all transactions made in reliance
upon the statements in Section 2 of this form shall be solely the responsibility of the trustee. The Company has not and will not provide tax advice
with respect to the contract or the trust. The Company intends to report taxes in the same manner as for a contract held by an individual, and
the trustee will be fully responsible for the trust’s tax reporting and payment of any federal, state, or local taxes, penalties, and fees relating to the
contract. The trustee releases the Company and its parent company, affiliates, and subsidiaries from any and all liability regarding the tax reporting
for the contract. The undersigned trustee(s) accepts all responsibility for any taxes that may arise from the ownership of this annuity, including the
10% early withdrawal penalty tax.
X X
SIGNATURE OF TRUSTEE #1 DATE SIGNATURE OF TRUSTEE #2 DATE
NAME AND TITLE OF OFFICER, IF TRUSTEE IS AN INSTITUTION
Please mail this form to: Fidelity Investments Life Insurance Company, P.O. Box 770001, Cincinnati, OH 45277-0050
Or in New York: Empire Fidelity Investments Life Insurance Company, P.O. Box 770001, Cincinnati, OH 45277-0051
Overnight Mail: Fidelity Investments, 100 Crosby Parkway, KC2Q, Covington, KY 41015
Fidelity Investments Life Insurance Company is licensed in all states except New York. In New York, insurance products are issued by
Empire Fidelity Investments Life Insurance Company, ® New York, NY. Products may not be available in all states. The contract’s financial
guarantees are solely the responsibility of the issuing insurance company.
405339.8.0
1.817266.108
X
SIGNATURE GUARANTEE FOR RESIGNING TRUSTEE
Fidelity Brokerage Services LLC, Member NYSE, SIPC