Fidelity IRA Beneficiary Designation - Instant Benefits Network

3. SIGNATURE
I understand that if I have not previously designated any beneficiary(ies) and choose not to designate any beneficiary(ies)
above, (or no designated beneficiary(ies) survives me), my beneficiary will be my surviving spouse, or if I do not have a
surviving spouse, my estate as provided in the applicable Fidelity IRA Custodial Agreement. For IRA-BDA and Roth-BDA
accounts, if no beneficiary is designated (or no designated beneficiary(ies) survives me), my beneficiary shall be my estate, as
provided in the applicable Fidelity IRA Custodial Agreement. I am aware that this form becomes effective when delivered to
and accepted by Fidelity, and will remain in effect until Fidelity receives and accepts another form with a later date.
The beneficiary information provided herein shall apply to the Fidelity IRA(s) that I listed in 2A for which Fidelity Management
Trust Company (or their affiliates and/or any successor custodian appointed pursuant to the terms of such IRAs) acts as custodian,
and shall replace all previous designation(s) I have made to my applicable Fidelity IRA(s).
Check here if you are currently receiving minimum required distributions from your retirement account.
Signature of Account Owner
Date:
X
PO Box 770001, Cincinnati, OH 45277-0042
Fidelity Brokerage Services LLC, Member NYSE, SIPC
Fidelity Portfolio Advisory Services SM is a service of Strategic Advisers, Inc., a registered investment adviser
and Fidelity Investments company. Accounts are carried by National Financial Services LLC, Member
NYSE, SIPC, a Fidelity Investments company.
367146 C.532-FORM-0304
1.707582.109
001070104