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Questions? Go to Fidelity.com/address or call 800-343-3548.
Address Change
Use this form to update the address or phone of an owner or authorized individual. Type on screen or fill in using CAPITAL letters and
black ink. If you need more room for check requests, make a copy of the relevant page.
Helpful To Know
•Y ou must already be an owner or an authorized • You can change your address at Fidelity.com/address and
individual (trustee, custodian, etc.) in order to change your combined statement address at Fidelity.com/statement.
an address on an account. • To change your address on employer-sponsored accounts,
• If your statements show accounts of other owners, ALL call your plan sponsor or go to Netbenefits.fidelity.com.
of those owners must sign this form. To “unbundle” a • To request duplicate statements, or to change the address
statement group, contact Fidelity. for them, you must complete the Duplicate Statements
Request form.
1. Account Owner(s)
Name
Louisiana Residents:
Consult a legal or tax
professional before Additional Owner/Authorized Individual Name
changing address on
joint accounts.
2. Accounts Involved Change of address will be applied only to the account(s) indicated.
ALL accounts associated with:
Social Security or Taxpayer ID Number Social Security or Taxpayer ID Number
Do NOT update any Fidelity
life insurance contracts.
If you check this ONLY on these accounts:
box, the address Account Number Account Number Account Number
will remain
unchanged on
any accounts
you do not Account Number Account Number Account Number
identify here.
Account Number Account Number Account Number
Do NOT update any Fidelity life insurance contracts.
3. New Address of Owner(s)
Legal/Residential Address This is your legal address used for tax reporting.
Address
City State/Province ZIP/Postal Code Country
Daytime Phone Extension
Mailing Address This may be a PO Box, drop box, or c/o location.
S
ame as legal/residential address
Address
City State/Province ZIP/Postal Code Country
Form continues on next page.
1.926101.102 Page 1 of 2 025830101
4. New Address of Additional Owner/Authorized Individual
Complete this section ONLY if a joint owner/authorized individual has a separate address. This individual must already be an owner or
authorized on the account.
Additional Owner/Authorized Individual
Legal/Residential Address This is your legal address used for tax reporting.
Address
City State/Province ZIP/Postal Code Country
Daytime Phone Extension
Mailing Address This may be a PO Box, drop box, or c/o location.
Same as legal/residential address
Address
City State/Province ZIP/Postal Code Country
5. Signatures and Dates
By signing below, you:
• Authorize Fidelity to act on all instructions given on this form.
• Accept all terms and conditions described in this form.
• Certify that all information you provided is correct to the best of your knowledge.
One owner signature is required unless you have a Mutual Fund Account (the account number begins with a 2 followed by two
letters), in which case all owners must sign.
PRINT OWNER NAME
OWNER SIGNATURE DATE MM/DD/YYYY
X X
SIGN
PRINT OWNER/AUTHORIZED INDIVIDUAL NAME
OWNER/AUTHORIZED INDIVIDUAL SIGNATURE DATE MM/DD/YYYY
X X
S IG N
Complete and sign Submit
Be sure to complete the form and collect all signatures. 1. Scan or take a digital photo of the ENTIRE form.
2. Visit Fidelity.com/upload to submit your files or photos.
You will receive a confirmation of your updates.
On this form, “Fidelity” means Fidelity Brokerage Services LLC and its affiliates. Brokerage services are
provided by Fidelity Brokerage Services LLC, Member NYSE, SIPC. 575108.5.0 (10/20)
1.926101.102 Page 2 of 2 025830102
