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Fidelity Disclaimer Certification
Use this form to certify a document disclaiming inherited assets greater than $100,000. The disclaimant and the disclaimant's attorney must sign in Section 3. Type on screen or print out and fill in using CAPITAL letters and black ink.
This form is not a disclaimer; you must attach a disclaimer to this form.
1. Decedent Information
Enter name and SSN of Deceased
Account Owner
Enter account numbers for which you are disclaiming
inherited assets.
First Name
Middle Name
Social Security/Taxpayer ID Number
Last Name
Account Number of Decedent
Account Number of Decedent
Account Number of Decedent
2. Disclaiming Party Information
Enter full first and last name as evidenced by a government-issued, unexpired document (e.g., driver's license, passport, permanent resident card).
First Name
Middle Name
Capacity Trustee, Joint Owner, Beneficiary, etc.
3. Signatures and Dates
Last Name
On this form, the term "Fidelity" refers to Fidelity Brokerage Services LLC, Fidelity Management Trust Co., Fidelity Personal Trust Co., National Financial Services LLC, Fidelity Distributors Company LLC, and their affiliates, successors, assigns, control persons, officers, directors, agents, and employees.
For Disclaimant: I, the above-named disclaiming individual (or fiduciary), do hereby certify to the following:
? That the attached disclaimer executed in connection with the above-listed Fidelity account(s) is an effective disclaimer under governing state law and that the disclaimer is qualified under Section 2518 of the Internal Revenue Code.
? That there are no conditions that bar this disclaimer and that Fidelity may rely on the attached disclaimer in determining the ownership of the account.
? I hereby indemnify, release, and hold harmless Fidelity from any claims, suits, damages, or causes of action of whatever
kind or nature relating to or arising out of Fidelity's acceptance of and reliance on the attached disclaimer.
? This indemnification and release shall be binding on my heirs, personal representatives, successors, and assigns.
A Medallion signature guarantee is required.
If the form is completed in a Fidelity Investor Center with all signers present, 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.
PRINT DISCLAIMANT NAME
MEDALLION SIGNATURE GUARANTEE
SIGN
DISCLAIMANT SIGNATURE
X
DATE MM/DD/YYYY
X
D AT E
For Disclaimant Attorney: I certify that I am a licensed attorney of good standing and that the attached disclaimer is valid and effective under governing state law, and that the disclaimer is qualified under Section 2518 of the Internal Revenue Code.
PRINT ATTORNEY NAME First, M.I., Last
STATE
SIGN
ATTORNEY SIGNATURE
X
DATE MM/DD/YYYY
X
1.955472.101
Page 1 of 2
029990101
Did you sign the form and attach any necessary documents? Send the ENTIRE form and any attachments to Fidelity Investments.
Questions? Go to or call 800-544-0003.
Regular mail Fidelity Investments PO Box 770001 Cincinnati, OH 45277-0039
Overnight mail
Fidelity Investments Account Reregistration Services 100 Crosby Parkway KC1C Covington, KY 41015
On this form, "Fidelity" means Fidelity Brokerage Services LLC and its affiliates. Brokerage services are provided by Fidelity Brokerage Services LLC, Member NYSE, SIPC. 635872.2.0 (11/19)
1.955472.101
Page 2 of 2
029990102
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