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Questions? Go to Fidelity.com or call 800-544-6666.
Standing Transfer Instructions Use this form to establish standing transfer instructions to another Fidelity brokerage account registered in someone else’s name. Establishing standing transfer instructions will allow you to request transfers of cash or shares to authorized accounts by phone. Do NOT use this form to establish standing transfer instructions for a Mutual Fund Only account. Type on screen or print out and fill in using CAPITAL letters and black ink. If you need more room for information or signatures, make a copy of the relevant page.
1. Account Owner(s) Name
Additional Owner/Authorized Individual Name
2. Establish New Standing Transfer Instructions You authorize transfers out of this Fidelity account: Fidelity Account Number
You authorize transfers to these Fidelity accounts: Fidelity Account Number
Account Owner Name
Fidelity Account Number
Account Owner Name
Fidelity Account Number
Account Owner Name
Fidelity Account Number
Account Owner Name
Fidelity Account Number
Account Owner Name
Fidelity Account Number
Account Owner Name
Form continues on next page.
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3. Signature(s) and Date(s) In this form, “Fidelity” refers to Fidelity Brokerage Services LLC and National Financial Services LLC, and their affiliates, employees, agents, representatives, shareholders, successors, and assigns as the context may require; and “You,” “you,” and “your” refer to all account holders. By signing below, you: • Authorize and direct Fidelity to transfer funds • Certify that all information you provided is • Agree that Fidelity will not be liable for any or securities from the originating account correct to the best of your knowledge. loss, liability, cost, or expense for acting identified above to any of the receiving upon all instructions believed to be genuine • Indemnify and hold Fidelity harmless from accounts identified above, at such time if Fidelity employs reasonable procedures to any liability related to any transfers initiated in and in such manner based on instructions prevent unauthorized transactions. connection with the information contained on received either in person or through a verified this form. This indemnification is in addition • Agree that (1) this authorization may only telephone communication from you. to, and in no way restricts, any of Fidelity’s be revoked by written notice to Fidelity in • Acknowledge that Fidelity is not responsible rights that may exist at law or under any other such time and manner as to afford Fidelity a for changes in the value of assets that may agreement you may have with Fidelity. reasonable opportunity to act upon it and (2) occur during the transfer process. Fidelity may terminate this Standing Transfer Instruction at any time in its sole discretion.
A Medallion signature guarantee is required. If the form is completed at a Fidelity Investor Center, the Medallion signature guarantee is not required. You can get a Medallion signature guarantee from most banks, credit unions, and other financial institutions. A notary seal/stamp is NOT a Medallion signature guarantee. MEDALLION SIGNATURE GUARANTEE
PRINT OWNER NAME
SIGN
OWNER SIGNATURE
X
D AT E
DATE
MM/DD/YYYY
X MEDALLION SIGNATURE GUARANTEE
PRINT ADDITIONAL OWNER/AUTHORIZED INDIVIDUAL NAME
SIGN
ADDITIONAL OWNER/AUTHORIZED INDIVIDUAL SIGNATURE
X
D AT E
DATE
MM/DD/YYYY
X
Did you sign the form? Send the ENTIRE form and any attachments to Fidelity Investments. Questions? Go to Fidelity.com or call 800-544-6666.
Use the postage-paid envelope, drop off at a Fidelity Investor Center, OR deliver to: Regular mail Overnight mail Fidelity Investments Fidelity Investments Attn: Distribution Services Attn: Distribution Services P.O. Box 770001 100 Crosby Parkway KC1D Cincinnati, OH 45277-0035 Covington, KY 41015-4325
On this form, “Fidelity” means Fidelity Brokerage Services LLC and its affiliates. Brokerage services are provided by Fidelity Brokerage Services LLC, Member NYSE, SIPC. 442696.9.0 (06/16)
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