University System of Maryland Fidelity Investments Distribution Form Instructions

Transcription

1 University System of Maryland Fidelity Investments Distribution Form Instructions Before you complete the Fidelity Investments Distribution Form, please read the following instructions. Each item listed below corresponds with the steps on the form and contains important information that you might want to consider before completing the form. Important: In order to be eligible to receive State Health Benefits, the Optional Retirement Program (ORP) plan mandates that a retiree, or retiree s surviving spouse or child, must be receiving a Periodic Distribution from the ORP. Receipt of a Retiree Periodic Distribution from your Maryland ORP account must follow directly at the end of your employment with a Maryland State Institution of Higher Education as an ORP. IMPORTANT: If all retirement funds are withdrawn from the ORP, then the State Health Benefits will stop. Questions: If you would like more information about distributions, including general tax implications, please call or, for the hearing impaired, (TTY) , Monday through Friday (except for New York Stock Exchange holidays), 8 a.m. to midnight Eastern time. Send your completed distribution form to one of the following addresses: Regular mail: Fidelity Investments, P.O. Box , Cincinnati, OH Overnight mail: Fidelity Investments, 100 Crosby Parkway, KC1E, Covington, KY STEP 1: PARTICIPANT INFORMATION A. Your Information Please enter your Social Security number or U.S. Tax ID number, date of birth (MM-DD-YYYY), first and last name, street address, city, state and ZIP, address (optional), and daytime and evening phone numbers. Address Change: Please be aware that if the address provided on the distribution form is different from the address on Fidelity s records, we will change your address as indicated on the distribution form. No distributions from your account will be processed until 15 calendar days have elapsed from the date of the address change, unless you provide a signature guarantee. All correspondence for your account will then be sent to the new address. If you do not want your address changed, but require the check to be sent to a different address, see Step 4. B. The Employer Sponsoring the Plan from Which You Are Requesting This Distribution Enter the name of the employer sponsoring the plan(s) from which you are requesting this distribution. If you are requesting a distribution for retirement plans sponsored by two different employers, you will need to complete a separate distribution form for each employer. C. Applicable Accounts Check the box(es) of the applicable plan(s), as well as the plan number(s) (if known), from which you would like your distribution made. If you are requesting a distribution from a nonqualified deferred compensation plan, such as a 457(b) or 457(f) plan, call Fidelity to determine the procedure for a distribution. STEP 2: REASON FOR DISTRIBUTION You must indicate a reason for the distribution. Check with your Administrator of the Plan(s) to determine which distribution options are available under the terms of your employer s plan. Federal tax law and your retirement plan allow distributions only for certain events. Please note the appropriate reason on the enclosed distribution form. Attainment of age 59½: Many 401(k) and 403(b) plans allow participants who are still employed by the employer who sponsored the plan to request a distribution from some or all of the contribution sources in the plan. Some plans, such as a qualified money purchase plan, may not allow employees to request distributions until the participant is no longer employed by the employer. Separation from service/termination from employment: Termination of employment from the plan sponsor from whose plan you are taking the distribution. Disability: For elective deferrals in a 401(k) plan or mutual fund value in a 403(b) plan, under Internal Revenue Code Section 72(m) (7), an individual is deemed to be disabled if unable to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment that can be expected to result in death or to be of long-continued and indefinite duration. Proof of disability may be required by the IRS, should you be audited. The 10% early withdrawal penalty is not imposed on distributions taken due to a disability that meet this IRS definition. In some situations for a qualified plan, a different definition of disability may apply to your account value for contribution sources that are not salary deferral sources.

2 STEP 2: REASON FOR DISTRIBUTION (CONTINUED) In-service withdrawal: This type of withdrawal may apply to certain contribution sources, such as the rollover source, even when the participant is younger than age 59½. In-service withdrawals may not be available from some sources and/or funds. Check with your employer or Fidelity at to determine the available sources and/or funds. Financial Hardship: Your plan sponsor determines the allowable reasons for a financial hardship distribution. Some possible reasons for a financial hardship distribution for you, your spouse, or, in some instances if your plan allows, your named beneficiary that fall under the IRS Safe Harbor guidelines include: Purchase of a primary residence Prevention of eviction Payment of certain unreimbursed medical bills Payment of post-secondary education tuition Repair of casualty damage to principal residence Funeral expenses When requesting a financial hardship distribution, depending on your plan, you generally must obtain the approval of your plan sponsor. Please indicate your reason for financial hardship on the line provided on the distribution form. If you are taking a distribution for a financial hardship reason, please note that you cannot choose a direct rollover or the systematic withdrawal plan. Beneficiary Account: If you are a beneficiary, once your beneficiary account has been established, you may use this form to make withdrawals from it. If you have not established your beneficiary account with Fidelity, please contact a Retirement Service Specialist at and ask for a Beneficiary Distribution Form. QDRO Alternate Payee Account: If you are an alternate payee, once your QDRO alternative payee account has been established, you may use this form to make withdrawals from it. STEP 3: PAYOUT REQUEST Fees may apply. See your prospectus or certificate for details. Please note that the applicable fees may lower your distribution amount. Step 3 is divided into three sections; however, only one section should be completed: A. Single Payout Full Payout: Select this option to distribute your entire account balance. Partial Payout: Select this option to withdraw a portion of your account balance. This can be done proportionately across all funds, or from specific sources/funds, subject to the retirement plan s distribution rules. If you choose to distribute money from a specific fund(s), please provide the five-digit fund number or the fund name. You can find this information on the Web at Fidelity.com or by contacting a Retirement Service Specialist at B. Systematic Payout: Select this option to establish ongoing, regular distributions. This option is not available for reasons of financial hardship. If you would like to receive your distribution in the form of periodic payments, you have two options: Please note that your plan sponsor may not allow for certain types of systematic payouts. Please call a Retirement Service Specialist at to verify which option is allowed by your plan sponsor. Specific Dollar Method: If you would like a specific amount sent to you on an installment basis, check the specific dollar method and list the amount you would like to receive each time. Please indicate the date (MM-DD-YYYY) you would like to begin receiving distributions and at what intervals (monthly, two per month, quarterly, or annually). This method will continue until the full balance you have specified has been distributed. Your plan may or may not allow you to change or discontinue this option, which you may do at any time in writing or by contacting a Retirement Service Specialist at Please allow five business days to process any change. Specific Period Method: If you would like to pay out your entire account balance over a period of time, indicate the date (MM-DD-YYYY) you would like to begin receiving distributions, the intervals (monthly, two per month, quarterly, or annually), and the number of years.

3 STEP 3: PAYOUT REQUEST (CONTINUED) C. Combination Payout: Select this option if you would like a cash payment and a rollover, or if you would like two or more rollovers. Any cash payment to you must be indicated in a percentage of the amount being distributed. Combination payouts are processed over multiple days, and may be processed using different net asset value(s) (NAV). All rollovers are processed prior to a check payment to you. If there are multiple rollovers, the rollover with the highest dollar amount will be processed first. Any rollovers external to Fidelity must occur prior to a rollover within Fidelity. Under each payout request (excluding systematic payouts), you have the following options for your payment method: Payable to You: If you choose this option, the proceeds from the distribution will be made payable to you and sent per your instructions. Deposit into a Fidelity Nonretirement Account: If you choose this option, all assets will be invested in Fidelity Cash Reserves, a money market fund. Enter your account number, or to open a new account, please go to Fidelity.com or attach an account application. Your money will be available in five to seven business days from the date of distribution. Rollover: This option is not available for financial hardship distribution requests. Taxes will not be withheld if we make the check payable to another investment provider for your benefit (FBO). Please be sure to include the name of the investment provider(s) for your rollover check(s). If your request is for a rollover into a Fidelity IRA account, please provide the Fidelity account number in the space provided. If you choose to roll this distribution over into an IRA that contains money from other sources, you may forfeit the right to roll over the value of this distribution into another retirement plan in the future. If you choose to roll over your after-tax contributions, it is your responsibility to keep track of your after-tax contribution amount. This is very important for future distributions from your IRA so that these funds will not be taxed again. If you do not have a Fidelity IRA, you must establish an account either online at Fidelity.com or by submitting a Fidelity Investments Rollover IRA Application. If your request is for a rollover into a Fidelity employer-sponsored account, please provide the Fidelity account number in the space provided. Any money invested in Fidelity mutual funds will be rolled over into the same Fidelity mutual fund(s) in which you are currently invested in the receiving account. Any non-fidelity assets will be rolled over proportionately to Fidelity Cash Reserves, a money market fund. When there is a direct rollover to a Fidelity IRA, Fidelity funds are transferred in kind and non-fidelity funds, or other investments, are liquated and transferred to a money market fund. When there is a direct rollover to a Roth IRA, all investments are liquidated and transferred into a money market fund. STEP 4: HOW YOU WOULD LIKE TO RECEIVE THE PAYMENTS Choose only one option to indicate how you would like to receive your distribution. By Check: If you choose this option, you should receive your check in seven to 10 business days from the date of distribution. By Check Sent by an Express Delivery Service: If you choose this option, a check will be sent by express delivery service. This option is not available for systematic payouts. A fee of not more than $35 will be deducted from your account. Checks sent by express delivery cannot be delivered to a P.O. Box. Express delivery is available in the United States and Canada. You should receive your check in four to five business days from the date of distribution. Electronic Funds Transfer (EFT): If you choose this option, be aware that EFT requires a 15-day set-up period prior to processing a distribution. Complete an EFT application and attach a voided check. Please go to Fidelity.com for an EFT application. If your plan is not set up for distributions via EFT, you will receive your distribution by check. This option is not available for rollovers. If you would like your check sent to an address other than the address listed in Step 1, please include the alternative address in this section. This will not change your address of record, future mailings, mailing of confirmations, or your state of residence for state income tax purposes. A signature guarantee is required when you select an alternative address if plan sponsor approval of the distribution is not required (see Step 7).

4 STEP 5: INCOME TAX WITHHOLDING Twenty percent (20%) federal income tax will be withheld from your taxable distribution if an eligible rollover distribution is not rolled over directly into another employer-sponsored retirement plan, or an IRA. The federal income tax withholding is mandatory if you elect one of the following distribution options: total cash distribution, partial cash distribution, or specific period, if less than 10 years. Eligible Rollover Distributions: Attainment of age 59½ Separation from service/termination from employment Disability (as defined by the Internal Revenue Code) In-service withdrawal Beneficiary account for spousal beneficiary QDRO alternate payee account for spousal payee Noneligible Rollover Distributions: Distributions that take place over a period of 10 or more years Nonspousal beneficiary distributions Minimum required distributions (MRD) Financial hardship Noneligible Rollover Distributions: Unless otherwise directed by you, we will automatically withhold 10% for federal income taxes as default withholding for any distribution that is not a systematic payment. Systematic payments are based on a joint return with three exemptions. You may choose to elect out of federal income tax withholding at the time. Please mark the box I elect not to have federal income taxes withheld from my taxable distribution. For more information about income tax withholding for distributions, please refer to IRS Form W-4P at How to Elect More Withholding for Federal Taxes: If you would like Fidelity Investments to withhold more than the mandatory 20% federal income tax or the default withholding, please specify so in Step 5. State Income Taxes: Please note that some states require Fidelity Investments to withhold state income taxes. We are unable to withhold additional state taxes. Nonresident Alien Withholding: A nonresident alien (NRA) is an individual who is not a U.S. citizen and resides outside the United States. As NRAs, these participants are subject to default withholding of 30%. However, these participants may be able to eliminate or reduce this withholding and have the applicable tax treaty rate applied to distributions that flow through Fidelity. In order to obtain the applicable tax treaty rate, you must have a valid Form W-8BEN on file with Fidelity. A blank form is available at Note: To be valid, the W-8BEN must contain a valid tax identification number. If you do not have a valid W-8BEN on file, you have two options: Request, complete, and return Form W-8BEN, indicating foreign country of residence. Decide not to complete and return the W-8BEN. The distribution will be processed and Fidelity will withhold taxes at a rate of 30%. Roth IRA Rollover: If you select in Step 3 to roll over into a Roth IRA any source that is not a Roth 401(k) or Roth 403(b) source, the amount that is rolled over to the Roth IRA is currently taxable income, except for an amount equal to any after-tax contributions. Fidelity does not withhold income taxes for this type of rollover. Prior to 2010, a rollover into a Roth IRA from these sources was available only if the taxpayer s modified adjusted gross income (MAGI) did not exceed $100,000. It is your responsibility to determine if you qualify for a rollover into a Roth IRA. Roth 401(k) or Roth 403(b) sources that are rolled over are also not considered taxable at this time and are not subject to the $100,000 MAGI limitation. Roth Accounts: If you receive a distribution from a Roth source and it is not rolled into a Roth IRA or to another Roth account, the earnings on the Roth source are taxable income unless the distribution is a qualified distribution. Information: You should carefully review the Special Tax Notice. Additional detailed taxation information is available on the IRS Web site and on state revenue department Web sites. On the IRS Web site, taxation of retirement plan distributions is in IRS Publication 575, and for 403(b) plans in IRS Publication 571. If you are a nonresident alien, the IRS Web site provides information for IRS Form W-8BEN and in IRS Publication 901.

5 STEP 6: SPOUSAL CONSENT Check with the employer who sponsors your plan(s), or contact Fidelity to determine if your spouse is required to provide consent in one or more plans where you are taking a distribution. Understand that when the distribution is from two or more plans, spousal consent may not apply to all plans. If spousal consent applies and your spouse has not completed Step 6, Fidelity will not process your distribution request for any plan that requires spousal consent. If you are single, please check the Single box and skip to Step 7. If you are married and spousal consent applies, then your spouse must sign the consent portion of this form in the presence of a notary public or, if allowed, a representative of your employer s plan. The spousal consent is valid for up to 180 days from when the spouse signs the form, unless the plan provides for a shorter period. Step 6 must include: Your spouse s signature and date Your notary s signature Your notary s seal/stamp (based on his/her state requirements) The date your notary s commission expires A plan representative can sign in place of a notary only if your plan allows. Please check with your benefits office or Fidelity Investments to see whether the plan(s) named in Step 1 allows this option. Please note that a signature guarantee is not a substitute for a notary. STEP 7: YOUR SIGNATURE Please sign and date in the space provided in order to avoid delays in processing your request. Be sure to send Fidelity a form with your original signature and not a copy of the form. A signature guarantee is required and: The amount of the distribution is more than $100,000 OR The distribution is not sent to the address of record OR Your address has changed within the last 15 days unless you are willing to accept a 15-day delay in processing your payment The requirement for a signature guarantee is NOT applicable when the distribution amount is more than $100,000 if (i) you are rolling over the distribution into a Fidelity retirement account or Fidelity IRA AND (ii) the name and address on both accounts are the same. All other signature guarantee requirements are still applicable. You may obtain a Medallion signature guarantee or any other signature guarantee for at least the estimated value of your distribution by contacting a Fidelity Investor Center, a national or state bank, savings banks in New York and Massachusetts, trust companies, federal savings and loan associations, and members of the New York, American, Boston, Midwest, or Pacific Stock Exchanges. Many of these organizations may participate in the Medallion signature guarantee program. When you obtain a signature guarantee, please tell the person who provides the signature guarantee of the estimated amount of the distribution and ask if the signature guarantee that he or she is providing is sufficient for the transferred amount. If the signature guarantee that you obtain is not a Medallion signature guarantee, please include the name and telephone number of the person who supplies the signature guarantee. Please note that a notarized signature is not a substitute for a signature guarantee. A Medallion signature guarantee contains a number with a letter prefix. The prefix letter indicates the degree of liability the guarantor is willing to assume. The degree of liability and the transaction amount must correspond to the letter prefix. If the letter prefix does not match the degree of liability, your distribution request will be returned for the proper letter prefix. Please see the following table: Medallion Prefix Degree of Liability Z Up to $10,000,000 Y Up to $5,000,000 X Up to $2,000,000 A Up to $1,000,000 B Up to $750,000 C Up to $500,000 D Up to $250,000 E* Up to $100,000 F* Up to $100,000 (Credit Unions) * Please note that Medallion signature guarantees with the letter prefix of E or F are required only if your address has changed within the last 15 days, or if your distribution amount is $100,000 or less and you request that your check be sent to a different address than the address of record.

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7 University System of Maryland Fidelity Investments Distribution Form Use this form if you wish to request a distribution from your employer s retirement plan. Important: In order to be eligible to receive State Health Benefits, the ORP plan mandates that a retiree, or retiree s surviving spouse or child, must be receiving a Periodic Distribution from the ORP. Receipt of a Retiree Periodic Distribution from your Maryland ORP account must follow directly at the end of your employment with a Maryland State Institution of Higher Education as an ORP. IMPORTANT: If all retirement funds are withdrawn from the ORP, then the State Health Benefits will stop. Questions: If you would like more information about distributions, including general tax implications, please call or, for the hearing impaired, (TTY) , Monday through Friday (except for New York Stock Exchange holidays), 8 a.m. to midnight Eastern time. A. Your Information Please use a black pen and print clearly in CAPITAL LETTERS. STEP 1: PARTICIPANT INFORMATION Social Security #: or U.S. Tax ID #: Date of Birth: Full Name: Address: City and State: ZIP: Daytime Phone: Evening Phone: B. The Employer Sponsoring the Plan from Which You Are Requesting This Distribution Name of Employer Sponsoring the Plan: C. Applicable Plans Please indicate the plans from which you would like a distribution. Fidelity will process for the plan type indicated below [403(b), 401(k), or 401(a)] even if the plan number listed is not correct. Please indicate your plan number, if known. 403(b) Plan #(s): 401(k) Plan #(s): 401(a) Plan #(s): If you indicate more than one plan number in this section, the distributions will be treated the same per your directions in Steps 3 and 4. Please submit a second form if you wish your plans to be treated differently. Page 7 of

8 Indicate a reason for the distribution: Attainment of age 59½ Separation from service/termination from employment Disability STEP 2: REASON FOR DISTRIBUTION In-service withdrawal. (Check with your employer before selecting this option. Most plans do not allow in-service withdrawals.) Financial hardship (Employer authorization is required.) Beneficiary account Qualified Domestic Relations Order (QDRO) alternate payee account STEP 3: PAYOUT REQUEST Complete only one section: Section A. Single Payment; Section B. Systematic Payment; or Section C. Combination Payment. If you do not request a rollover, taxes may be withheld. See Step 5 for income tax withholding information. A. Single Payout Complete this section if you would like all your distributed funds to be treated the same way. Complete only one option below (either Full Payout or Partial Payout). Then, skip to Step 4. Full Payout: 100% of the funds in your account will be distributed via the method indicated below. (If you do not check a box below, Fidelity will distribute the funds made out to you.) Pay directly to me. Deposit into a Fidelity nonretirement account. Account # Roll over the entire amount. (Check one box below and complete information on the investment provider.) Traditional IRA* OR Roth IRA* OR Employer-sponsored retirement account** Provide the receiving investment provider s name: *If this is a Fidelity traditional IRA or a Fidelity Roth IRA Account, please provide the account number. #. **If this is a Fidelity employer-sponsored account, please provide the plan name and number (if known)., #. Partial Payout. A portion of the funds in your account will be withdrawn. (Select one Amount and one Method below. Complete the information for the Amount and for the Method that you select.) Amount Dollar amount. I request that this amount $ be withdrawn from my account. (This amount will be taken proportionately across all funds and sources available for withdrawal.) OR Percent. I request that % be withdrawn from my account. (This amount will be taken proportionately across all funds and sources available for withdrawal.) OR Specific sources/funds. I request that the source(s) or fund(s) indicated below be withdrawn from my account. (Select a source and then for that source, select 100% or a dollar amount. The withdrawal will be pro-rated for all funds in the source unless you designate a fund.) From Source (Check one): Pretax After-Tax Roth Amount: 100% OR $, Fund # or Name: Continued on next page. Page 8 of 14

9 STEP 3: PAYOUT REQUEST (CONTINUED) Amount (continued) From Source (Check one): Pretax After-Tax Roth Amount: 100% OR $, Fund # or Name: From Source (Check one): Pretax After-Tax Roth Amount: 100% OR $, Check here if additional fund selections are attached. Fund # or Name: Method: The amount indicated above will be distributed via the method indicated below. (Check one of the three boxes below and complete the information for that box. If you do not check a box below, the Pay directly to me box will apply.) Pay directly to me. Deposit into a Fidelity nonretirement account. Account # Roll over the entire amount. (Check one box below and complete information on the investment provider.) Traditional IRA* OR Roth IRA* OR Employer-sponsored retirement account** Provide the receiving investment provider s name: *If this is a Fidelity traditional IRA or a Fidelity Roth IRA Account, please provide the account number. #. **If this is a Fidelity employer-sponsored account, please provide the plan name and number (if known)., #. B. Systematic Payout Complete this section if you would like a recurring automatic payment paid from the account(s) listed in Step 1C. If you indicated more than one plan, the amount indicated below will be taken proportionately from the plans listed. (Systematic Withdrawal Payments are not available for financial hardships or rollover. If you require a Systematic Payment for a Minimum Required Distribution, please complete the Participant/Retiree Minimum Required Distribution Form.) Specific Dollar Method Pay me $ Beginning:, Monthly OR Twice per month OR Quarterly OR Annually OR Withdraw proportionately across all available funds Withdraw from single fund number or name: (Systematic Withdrawal Payments may be discontinued if your single fund s available balance cannot support the payment amount.) Specific Period Method (proportionately across all available funds) Beginning: Monthly OR Twice per month OR Quarterly OR Annually, for years Continued on next page. Page 9 of

10 STEP 3: PAYOUT REQUEST (CONTINUED) C. Combination Payout Please complete this section if you would like a cash payment and a rollover, or if you would like two or more rollovers. Source information (Please only complete the section(s) below that are applicable to your account.) Pretax 100% of the funds in your account will be distributed via the method indicated below. (If you do not check a box below, Fidelity will distribute the funds made out to you.) Pay directly to me. Deposit into a Fidelity nonretirement account. Account # Roll over % and pay the remainder to me. (If no percentage indicated, rollover will be for entire amount.) Check one box below and complete information on the investment provider: Traditional IRA* OR Roth IRA* OR Employer-sponsored retirement account** Provide the receiving investment provider s name: *If this is a Fidelity traditional IRA or a Fidelity Roth IRA Account, please provide the account number. #. **If this is a Fidelity employer-sponsored account, please provide the plan name and number (if known)., #. After-Tax Your after-tax contributions to be paid out as follows (This election will apply to your after-tax contribution amount only. Any earnings on your contributions are considered taxable income. Please use the Pretax section above to indicate how earnings on your after-tax contributions should be distributed.) Pay directly to me. Deposit into a Fidelity nonretirement account. Account # Roll over the entire amount (Check one box below and complete information on the investment provider): Traditional IRA* OR Roth IRA* OR Employer-sponsored retirement account** Provide the receiving investment provider s name: *If this is a Fidelity traditional IRA or a Fidelity Roth IRA Account, please provide the account number. #. **If this is a Fidelity employer-sponsored account, please provide the plan name and number (if known). Roth Roth contributions to be paid out as follows: Pay directly to me. Deposit into a Fidelity nonretirement account. Account #, #. Roll over the entire amount. (Check one box below and complete information on the investment provider.) Roth IRA* OR Employer-sponsored retirement account that accepts Roth funds** Provide the receiving investment provider s name: *If this is a Fidelity Roth IRA Account, please provide the account number. # **If this is a Fidelity employer-sponsored account, please provide the plan name and number (if known):., #. Page 10 of 14

11 STEP 4: INDICATE HOW YOU WOULD LIKE TO RECEIVE THE PAYMENT(S) Complete this section if you elected to have funds paid out to you, if you selected a Systematic Withdrawal Payment, or if you requested a rollover to a vendor other than Fidelity. By check. (You should receive your check in 7 10 business days from the date of distribution.) By check sent by an express delivery service (NOT available for Systematic Withdrawal Plan). I understand that a fee of not more than $35 will be deducted from my account. This check cannot be delivered to a P.O. Box. Electronic Funds Transfer (EFT) (also known as Direct Deposit) requires a waiting period of up to 15 days prior to processing a distribution. Complete an EFT application and attach a voided check. Note: If your plan is not set up for distributions via EFT, you will receive your distribution by check. Alternate address for check mailing only If you need to have your check sent to an address other than your address of record, please complete this section. This will not change your address of record indicated in Step 1, or your state of residence for state income tax purposes. First Name: Last Name: Mailing Address: Address Line 2: City: State: ZIP: Daytime Phone: A signature guarantee (see Step 7) is required when you select an alternate address. You may obtain a signature guarantee from a bank, broker, dealer, municipal securities dealer, government securities broker, credit union (if authorized under state law), national securities exchange, registered securities association, clearing agency, or savings association. Please inform the person providing the signature guarantee of the approximate amount of the distribution. STEP 5: INCOME TAX WITHHOLDING Payments subject to withholding are either taxable eligible rollover amounts or taxable noneligible rollover amounts. Please refer to the instructions for more information on mandatory withholding and default withholding. Federal Income Taxes I elect not to have federal income taxes withheld from my taxable distribution. (Eligible rollover amounts not directly rolled over are subject to mandatory withholding of 20% for federal income taxes. A payee cannot elect out of this withholding.) I elect to have a total of % withheld for federal income taxes. Taxable distributions to nonresident aliens are subject to 30% withholding unless a valid IRS Form W-8BEN is submitted to claim no withholding or a reduced rate of withholding on the distribution. State Income Taxes I elect not to have state income taxes withheld from my distribution. (Please note that some states require state income taxes to be withheld. Fidelity will withhold state income taxes for these states unless this form is accompanied by a W-4P form.) I elect to have state income taxes withheld according to state tax tables. (Please note that Fidelity is unable to withhold additional state taxes.) If you are under age 59½, a 10% early distribution tax penalty may apply to the taxable amount not rolled over to an IRA, or another retirement plan, unless you qualify for an exemption from the penalty. Please understand that you may owe additional taxes in addition to the amount withheld. Page 11 of

12 STEP 6: SPOUSAL CONSENT You should check with Fidelity Investments or the employer who sponsored the plan or plans named in Step 1 to determine if a married participant is required to obtain consent from a spouse in order to request a distribution. If spousal consent applies, the person named in Step 1A must check the box for either Single or Married. Spousal consent does not apply to distributions from beneficiary accounts or QDRO alternate payee accounts. Single I certify under penalties of perjury that I am not married as of the date that this form is signed. I understand that if I marry after this date, but before distribution commences, the rules for married individuals will apply to me. Married I certify that I am married and that distributions must be made to me in the form of a qualified joint and survivor annuity, unless I have elected another form of distribution and my spouse signs the spousal consent section below in the presence of a notary public (or plan representative, if authorized by my plan). To Be Completed by the Participant s Spouse: I am the spouse of the participant named in Step 1. I hereby consent to the election of distribution as indicated by my spouse, to have benefits paid in the form specified rather than in the form of a qualified joint and survivor annuity. Further, I hereby acknowledge that I understand: (1) that the effect of my consent may result in the forfeiture of benefits I would be entitled to receive upon my spouse s death; (2) that my spouse s waiver of a qualified joint and survivor annuity, if applicable, is not valid unless I consent to it; (3) that my consent is voluntary, and is irrevocable unless my spouse revokes the waiver; and (4) that my consent must be witnessed by a notary public or plan representative. I understand that if the distribution described in this form is not processed within 180 days of the date I sign this form, my consent expires. Signature of Participant s Spouse: X Date: To be completed by a notary public: Note: A signature guarantee cannot be substituted for a notary. Sworn before me this day In the State of, County of Notary Public Signature: X My Commission Expires: Notary stamp must be in the above box. Some states require that the Notary Public indicate the expiration date in order for the notary to be valid. If this is a requirement for the state listed above and is not included below, your spouse s consent will not be considered valid until the expiration date is received. Or, witnessed by Plan Representative: (if provided for under the terms of the plan or plans named in Steps 1B and 1C): X Date: Please print name of authorized Plan Representative signing above: First and Last Name of Plan Representative: Page 12 of 14

13 STEP 7: YOUR SIGNATURE Please carefully read each bullet point below and sign in the appropriate space. I acknowledge that in order to be eligible to receive State Health Benefits, the ORP plan mandates that a retiree, or retiree s surviving spouse or child, must be receiving a Periodic Distribution from the ORP. Receipt of a Retiree Periodic Distribution from your Maryland ORP account must fol low directly at the end of your employment with a Maryland State Institution of Higher Education as an ORP. IMPORTANT: If all retirement funds are withdrawn from the ORP, then the State Health Benefits will stop. If I am a U.S. citizen or other U.S. person (including a resident alien individual), I hereby certify, under penalties of perjury, that the Social Security number or U.S. taxpayer identification number I have provided is correct and valid. If I am a nonresident, I have attached U.S. Form W-8BEN and included my U.S. taxpayer identification number in order to claim tax treaty benefits, if applicable. I understand that if I have not attached form W-8BEN, 30% of the taxable distribution will be withheld for United States federal income taxes. To the extent that I have requested that my pretax funds be rolled over into a Roth IRA, I understand that the taxable amount rolled over is taxable income. I acknowledge that I received and understood the Special Tax Notice and, when applicable, the Participant Distribution Notice and the Qualified Joint and Survivor Notice. I acknowledge that if I select a method where two or more withdrawals apply, that each withdrawal may be paid on a different business day and that the market value will be determined on the day of the withdrawal. I understand that redemption fees may apply, contingent on the funds held in my account, and may lower my distribution amount. (Please consult your fund prospectus for short-term redemption fee details.) I acknowledge that: (1) when I am issued a check or a distribution as an electronic fund transfer, my investments are being redeemed, (2) when I request a direct rollover to a non-fidelity IRA or to another Fidelity employer-sponsored retirement plan, my investments are being redeemed, (3) when my direct rollover is to a Fidelity Roth IRA, my investments are being redeemed and the proceeds will be deposited into a money market fund, and (4) when my direct rollover is to a traditional Fidelity IRA, Fidelity mutual funds and eligible non-fidelity funds are being transferred in kind and all other investments are being redeemed and the proceeds will be deposited into a money market fund. Your Signature: X Date: Person named in Step 1A. Check this box if you are signing this form as an agent under a Power of Attorney, Guardian, or Conservator. Your authority to sign this form must be on file with Fidelity. A signature guarantee is required if plan sponsor approval of the distribution is not required (Step 6) and: The amount of the distribution is over $100,000*, OR The distribution is not sent to the address of record, OR Your address has changed within the last 15 days * A signature guarantee for a distribution over $100,000 does not apply when the payment is going to a Fidelity IRA, Fidelity Roth IRA, or a Fidelity nonretirement account when that account has the same name and address currently on record for the plan named in Step 1. Place signature guarantee stamp in box. If the guarantee stamp to the right is not a Medallion signature guarantee, print the name of the person issuing the guarantee, his or her phone number, and the amount of the signature guarantee: The amount of the signature guarantee must meet or exceed your distribution amount. Guarantees for less than the distribution amount will delay your request. Note: A notary public cannot provide a signature guarantee. To avoid possible delays in processing your request, please refer to the instructions. Page 13 of

14 STEP 8: MAILING INSTRUCTIONS Instructions: Return this form, unless otherwise directed, to: Fidelity Investments, P.O. Box , Cincinnati, OH If you wish to send your form overnight, please ship to: Fidelity Investments, 100 Crosby Parkway, KC1E, Covington, KY Here is a checklist to ensure that your request is in good order. Please verify that you have provided: Reason for Distribution Employer Signature, if applicable Marital Status (If married, spousal consent Payout Request Information Your Original Signature if applicable) SSN or U.S. Tax ID # Medallion Level For Fidelity Use Only Prefix Degree of Liability Z $10,000,000 Y $5,000,000 X $2,000,000 A $1,000,000 B $750,000 C $500,000 D $250,000 E $100,000 F $100,000 (Credit Unions) Fidelity Investments Institutional Operations Company, Inc. Page 14 of 14