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1 Page 1 of 8 Questions? Go to or call fidelity Account Inherited IRA for a Non-Spouse IndividualUse this application if you are a non-spouse beneficiary of an IRA or a qualified retirement plan and the original account owner is deceased and you need to open an Inherited IRA or Inherited Roth IRA. Type on screen or print out and fill in using CAPITAL letters and black ink. If you need more room for information or signatures, use a copy of the relevant page. Important to UnderstandBy signing this application, you acknowledge that: fidelity Brokerage Services LLC ( FBS ) will perform brokerage and administrative services. National Financial Services LLC ( NFS ) will maintain the assets in a brokerage account and provide administrative services. fidelity Management Trust Company ( FMTC ) will act as IRA Custodian.

2 FBS, NFS, and FMTC are together referred to herein as fidelity . Important documents related to your account include the fidelity IRA Custodial Agreement and Disclosure Statement or fidelity Roth IRA Custodial Agreement and Disclosure Statement and fidelity Brokerage Retirement Account Customer Agreement ( Customer Agreement ), and other relevant information delivered from time to time. Uninvested money in your account is held in your Core Position ( Core Position ) until you direct otherwise. Your Core Position will be the fidelity Government Money Market Fund, a money market mutual fund. Other Core Position options may be available after you open your account. Please note that in certain circumstances, such as if fidelity determines you reside outside the United States, the Core Position will operate differently.

3 Please refer to the Customer Agreement for further to KnowRegarding this account: If the deceased was over 72* and had not withdrawn his or her total required minimum distribution (RMD) in the year of death, see Section 7. Use this form if you are a non-spouse individual over the age of 18. Please use the fidelity Inherited IRA for Minors/Non-Individuals application if you are inheriting from the original owner and: You are a minor or incapacitated person that is named as the beneficiary. Your intent is to open a Trust Inherited IRA. The deceased IRA owner s or a deceased beneficiary s estate is inheriting. You represent an entity like a charity, university, or other educational learn more about these options, visit Deceased IRA Owner s Information Include a copy of deceased s death certificate and a state inheritance tax waiver, if required by the deceased s state of are you directly inheriting this IRA from?

4 Tell us by completing the fields Name Middle NameLast NameSocial Security NumberDate of Birth MM DD YYYYDate of Death MM DD YYYY Only complete the below section if you are the beneficiary of an inherited IRA. Do not complete this section if a spouse originally inherited the account and moved to an IRA in their name. Please call Inheritor Services at 800-544-0003 with any Owner s First NameMiddle NameOriginal Owner s Last NameSocial Security NumberDate of Birth MM DD YYYYDate of Death MM DD YYYY You are known as a successor beneficiary if you are inheriting an IRA after the original beneficiary s 030190901 Account owner must sign and date at the end of section 8. Form continues on next page. Page 2 of 82. Selection of Type of Account Indicate the type of account you plan to establish.

5 For more information about options available to you as an owner inheriting retirement assets, go to a New Account Inherited IRA Inherited Roth IRA 3. Your Information First Name Middle NameLast NameDate of Birth MM DD YYYYE mailSocial Security or Taxpayer ID NumberDaytime PhoneExtension Residential Address (where you live) This is your legal address used for tax reporting. Street AddressCityStateZIPM ailing Address May be a box, drop box, or c/o location Same as legal / residential address Default if no other information indicated AddressCityStateZIPC itizenship citizen Foreign citizen Information in this box must be completed. Permanent resident Non-permanent resident Nonresident of of CitizenshipCountry of Tax Residency Only applicable to nonresidents of the , State/Province, and Country of Birth Passport DHS Permanent Resident Card Employment Authorization Document Foreign National Identity DocumentEnter full name as evidenced by a government-issued, unexpired document ( , driver s license, passport, permanent resident card).

6 Indicate your citizenship one and attach a copy of a valid and unexpired government ID showing number and photo. To claim tax status, also complete and submit an IRS Form W-8 BEN. Account owner must sign and date at the end of section 8. Your Information continues on next page. Page 3 of 8 Income Source Employed: Self-employed: OccupationEmployer Leave blank if AddressCityState/ProvinceZIP/Postal CodeCountry Retired: Not employed: Source of Income Pension, investments, spouse, you are employed by or associated with a broker-dealer, stock exchange, exchange member firm, the Financial industry Regulatory Authority (FINRA), a municipal securities dealer, or other financial institution, or are the spouse or an immediate family member residing in the same household of someone who meets the aforementioned employment criteria, provide the company s name and address below.

7 By providing this information and complet-ing this form, you hereby authorize fidelity to provide the associated person s employer with duplicate copies of confirmations and statements, or the transactions data contained therein, for your account(s) and any accounts you choose to have on a consolidated statement for purposes of their compliance NameCompany AddressCityState/ProvinceZIP/Postal CodeCountryAffiliationsIf you, your spouse, or any of your relatives (including parents, in-laws, and/or dependents, etc.), living in your home (at the same address), is a member of the board of directors, a 10% shareholder, or a policy-making officer of a publicly traded company (an Affiliate ), you must provide the information below. If there are more than two Affiliates, make a copy of this s Company NameTrading Symbol or CUSIPA ffiliate s Company NameTrading Symbol or CUSIP4.

8 Funding MethodCheck all funding options that apply. Transfer Inherited Assets T ransfer from deceased s fidelity IRA: All shares will be transferred in kind. Account number indicated below can be for a Traditional or Roth IRA and will be transferred to accounts selected in Section IRA Account Number T ransfer an Inherited IRA from another firm Include a completed Transfer of Assets form and include a copy of the deceased s account rules vary among firms. Check with the firm s guidelines to ensure that the original account owner s assets are eligible for transfer into a fidelity Inherited one and provide regulations require us to ask for this a person associated with a member firm, you are obligated to receive consent from that firm. fidelity has existing consent agreements with many firms for their employees to maintain accounts with fidelity and to deliver transactional data.

9 If your firm is not one of them, fidelity will attempt to contact your firm s compliance IRA Account NumberAccount owner must sign and date at the end of section 8. Funding Method continues on next page. 3. Your Information, continuedPage 4 of 8 Rollover Roll over from an employer-sponsored account. If plan is recordkept at fidelity , contact us at 800-605-4015 for next steps. Please indicate Name of Employer below:Name of Employer If Rollover is from a plan not at fidelity , you will need to contact the plan administrator by calling the toll-free number on the statement of the account you have of Employer s Plan Recordkeeper Name Where your assets are heldRecordkeeper PhoneAddressCityStateZIPPlan ID/Account NumberApproximate Rollover Amount$. Send a letter of acknowledgement to the Plan Administrator to the address provided above on your behalf.

10 OR Enclosed is a check with this application, or the plan has been contacted and will be mailing fidelity a check. Make check payable and send to: FMTC, FBO (your name), Direct Rollover, Box 770001, Cincinnati, OH, Account Features Optional. Additional features may be available for your account(s). Call fidelity or go to Withdrawals You can create a schedule of Automatic Withdrawals from your account to help satisfy your RMD or establish an income stream. Go to for more Delivery If you provided an email address in Section 3 and unless you indicate otherwise below, all materials will be sent to you electronically. To confirm electronic delivery, respond to the Electronic Delivery Agreement and Consent, which we will email to you. To choose delivery by mail, check one or more boxes below.