Fill and Sign the Suny Potsdam Request 2014 2019 Form

Questions? Call 1-800-634-9361. Withdrawal – One-Time Fidelity Income Advantage® Annuity and Fidelity Freedom Lifetime Income® Annuity Use this form to make a one-time withdrawal from or to surrender your annuity contract. Type on screen or print out and fill in. For best results, use CAPITAL letters and black ink. Need more room for information or signatures? Use a copy of the relevant page. Helpful to Know •  or Fidelity Income Advantage® annuities, you cannot F •  o make one-time withdrawals from more than one T annuity, use a separate form for each contract. make a withdrawal from assets allocated to the fixed income portion of your contract. •  ote that only two partial withdrawals are allowed each N year and that withdrawals reduce your contract’s income •  or annuity funds, note that withdrawals could trigger F value and the amount available for future withdrawals. redemption fees (see the applicable fund prospectus). •  eview your contract for conditions and policies R • t is your responsibility to ensure that your withdrawals I that apply to withdrawals from your annuity, including comply with IRS rules. All transactions made using this frequent trading policies. form are reported to the IRS. You may want to consult a tax advisor. Contract Number 1. Contract Owner(s) Contract Owner Name Joint Contract Owner Name if applicable Phone numbers will be used if we have questions, but will not be used to update your account information. Trust or Entity Name if applicable Evening Phone Daytime Phone 2. Withdraw Part of Your Contract Value Extension Skip to Section 3 if you are requesting a full withdrawal. The amount you receive will be the amount you request MINUS any taxes and fees triggered by your withdrawal. Note that your withdrawal will reduce your income value and future withdrawal amount. See your contract and prospectus for details. Complete ONLY the subsection for the type of your annuity. Fidelity Income Advantage Annuity Withdrawals will be made from assets in the variable portion of your contract and will be taken proportionately from all your variable investments. Dollar Amount $ $500 minimum Fidelity Freedom Lifetime Income Annuity Check ONLY one request option and provide any required information. M  aximum partial withdrawal amount available Maximum is the amount that will reduce your variable income amount to $1,200 per year ($100 per month). ONLY the following amount:  Dollar Amount $ $500 minimum Form continues on next page. 1.804453.112 Page 1 of 3 021390301 3. Full Withdrawal The amount you receive will be the amount you request MINUS any taxes and fees triggered by your withdrawal. Note that your withdrawal may affect the size of any future payments, particularly if you bought your annuity within the past five years. See your contract and prospectus for more details. Fidelity Income Advantage Annuity Withdrawals will be made from assets in the variable portion of your contract and will be taken proportionately from all your variable investments. W  ithdraw full liquidity value Withdrawal period will end and reduced payments will continue from your contract as long as you live. Fidelity Freedom Lifetime Income Annuity The amount you receive will be the amount you request MINUS any taxes and fees triggered by your withdrawal. W  ithdraw full liquidity value Constitutes a full withdrawal (surrender) of your contract if you request within the first 5 years of your contract. If requested after 5 years, reduced payments will continue from your contract as long as you live. 4. Withdrawal Method  Be sure to note whether the withdrawal method you choose requires that you obtain a Medallion signature guarantee in Section 6. Check one and provide any required information. Provide bank information ONLY if there are multiple EFT instructions on the contract identified in Section 1. D  irectly deposited to a Fidelity non-retirement account: Withdrawals to a brokerage account will be deposited to the core position only. Requires Medallion signature guarantee if going to an account of which you are not an owner. Fidelity Non-retirement Account Number Fidelity Fund Name or Symbol Mutual fund accounts ONLY. Electronic funds transfer (EFT) to bank or credit union account using EFT instructions ALREADY IN PLACE on the  contract. To add EFT to a contract, go to fidelity.com/EFT. Bank Account Number Payee cannot be another financial institution. Bank Name C  heck paid to an alternate payee or mailed to an alternate address: Requires Medallion signature guarantee. Alternate Payee Name Address City State/Province Zip/Postal Code Country Default if no choice indicated or if we are unable to process your choice. C  heck mailed to the address of record Requires Medallion signature guarantee if the contract’s address of record has been changed within the past 15 days AND the withdrawal amount is over $10,000. 5. Tax Withholding  Withdrawals from your annuity are subject to federal and, where applicable, state income tax withholding, unless you choose not to have withholding apply below (and if you provided a U.S. address). If you do not elect out of withholding, federal income tax will be withheld at the rate of 10% from the taxable portion of your annuity withdrawal amount, unless you indicate a higher percentage below. If you choose not to have withholding apply, or if you do not have enough federal income tax withheld, you may be responsible for payment of estimated tax. You may incur penalties under the estimated tax rules if your withholding and estimated tax payments are not sufficient. Withholding instructions provided will remain effective for all withdrawals until you either revoke them or give us new instructions. State Federal Check one in each column. Contract owner’s legal /  residential address determines which state’s tax rules apply. D  o NOT withhold federal taxes D  o NOT withhold state taxes unless required by law W  ithhold federal taxes at the rate of: W  ithhold state taxes at the applicable rate Percentage % No dollar amounts. Note that if there is federal withholding, certain states require that there also be state withholding.  ithhold state taxes at the rate, or in the amount, of: W Percentage Dollar Amount % or $ Form continues on next page. 1.804453.112 Page 2 of 3 021390302 6. Signature and Date ALL contract owners must sign and date. By signing below, you: •  uthorize and request Fidelity Investments A Life Insurance Company to make the withdrawals indicated on this form from the contract listed In Section 1. •  cknowledge that withdrawals will be taxed A as ordinary income, and may be subject to a 10% early withdrawal penalty if taken before age 59½. • ndemnify Fidelity and its agents, affiliates, I successors, and employees from any liability in the event that you fail to meet the IRS requirements. •  uthorize and request Fidelity Investments A Life Insurance Company to make the withdrawals indicated on this form from the contract listed In Section 1. •  gree that if you withdraw all or part of the A variable portion of your contract after your first annuity income date but on or before its fifth anniversary, you will forfeit the portion of your purchase payment intended to provide annuity income to annuitants still living after the withdrawal period. •  cknowledge that if any portion of this A contract was funded via a partial exchange of an existing annuity contract within the last 6 months, any withdrawals from the existing or new contract that are not part of an annuity income program could nullify the partial 1035 protection or result in an adverse tax consequence. •  ertify under penalties of perjury that C you are U.S. citizen or other U.S. person (including a resident alien individual) and that the tax ID you provided on the Fidelity Annuity Contract associated with this withdrawal (or as updated in a subsequent communication to Fidelity) is your correct tax identification number. Customers surrendering contracts •  nderstand that Fidelity will be released U from any other contractual obligation and that the contract listed in Section 1 will be canceled. •  ertify that there are no existing assignC ments and that no bankruptcy petition has been filed by or against you. Customers requesting EFTs •  uthorize and request Fidelity to make A EFT withdrawals from the contract listed in Section 1 by initiating debit entries to that contract. A Medallion signature guarantee is required if: •  our withdrawal amount is over Y •  ithdrawals are sent to someone other W $100,000. than the account owner. •  ontract’s address of record has been C changed within the past 15 days AND the withdrawal amount is over $10,000. You can get one from most banks, credit unions, and other financial institutions. A notary seal/stamp is NOT a signature guarantee. Print Contract Owner Name MM DD YYYY D AT E Date MEDALLION SIGNATURE GUARANTEE SIGN Owner Signature Print Joint Contract Owner Name MM DD YYYY D AT E Date MEDALLION SIGNATURE GUARANTEE S IG N Owner Signature Individual providing signature guarantee Providing this information will avoid delay or rejection of your request. Guarantor Name Phone Did you sign the form? Send the ENTIRE form to Fidelity. Questions? Call 1-800-634-9361. Extension Regular Mail Except NY Regular Mail NY only Overnight Mail Annuity Service Center PO Box 770001 Cincinnati, OH 45277-0050 Annuity Service Center PO Box 770001 Cincinnati, OH 45277-0051 Fidelity Investments 100 Crosby Parkway, KC2Q Covington, KY 41015 Fidelity insurance products are issued by Fidelity Investments Life Insurance Company (FILI), 100 Salem Street, Smithfield, RI 02917, and, in New York, by Empire Fidelity Investments Life Insurance Company ®, New York, N.Y. FILI is licensed in all states except New York. A contract’s financial guarantees are subject to the claims-paying ability of the issuing insurance company. Fidelity Brokerage Services LLC, Member NYSE, SIPC. 494734.12.0 (03/14) 1.804453.112 Page 3 of 3 021390303