Download Form - Fidelity
Download Form - Fidelity
Download Form - Fidelity
Create successful ePaper yourself
Turn your PDF publications into a flip-book with our unique Google optimized e-Paper software.
4 Add oR Remove A TRuSTee (Complete this section only if adding or removing a trustee from an existing trust.)<br />
X<br />
Adding a co-trustee<br />
I (We), (name of co-trustee), certify that I am<br />
(we are) the co-trustee of the above-named trust in accordance with the terms of the trust instrument.<br />
Removing a trustee<br />
Death of trustee. (name of deceased trustee)<br />
Resignation of trustee. I (name of resigning trustee),<br />
certify that I am resigning as trustee of the above-named trust.<br />
SIGNATURE OF RESIGNING TRUSTEE DATE<br />
5 TRuSTee(S) SIgnATuRe(S)<br />
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<br />
exercise ownership rights under the contract in accordance with the terms of the trust. The trustee(s) agrees that all transactions made in reliance<br />
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<br />
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<br />
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<br />
contract. The trustee releases the Company and its parent company, affiliates, and subsidiaries from any and all liability regarding the tax reporting<br />
for the contract. The undersigned trustee(s) accepts all responsibility for any taxes that may arise from the ownership of this annuity, including the<br />
10% early withdrawal penalty tax.<br />
X X<br />
SIGNATURE OF TRUSTEE #1 DATE SIGNATURE OF TRUSTEE #2 DATE<br />
NAME AND TITLE OF OFFICER, IF TRUSTEE IS AN INSTITUTION<br />
Please mail this form to: <strong>Fidelity</strong> Investments Life Insurance Company, P.O. Box 770001, Cincinnati, OH 45277-0050<br />
Or in New York: Empire <strong>Fidelity</strong> Investments Life Insurance Company, P.O. Box 770001, Cincinnati, OH 45277-0051<br />
Overnight Mail: <strong>Fidelity</strong> Investments, 100 Crosby Parkway, KC2Q, Covington, KY 41015<br />
<strong>Fidelity</strong> Investments Life Insurance Company is licensed in all states except New York. In New York, insurance products are issued by<br />
Empire <strong>Fidelity</strong> Investments Life Insurance Company, ® New York, NY. Products may not be available in all states. The contract’s financial<br />
guarantees are solely the responsibility of the issuing insurance company.<br />
405339.8.0<br />
1.817266.108<br />
X<br />
SIGNATURE GUARANTEE FOR RESIGNING TRUSTEE<br />
<strong>Fidelity</strong> Brokerage Services LLC, Member NYSE, SIPC