Fillable Printable Trustee Certification Form - Fidelity Investment
Fillable Printable Trustee Certification Form - Fidelity Investment
Trustee Certification Form - Fidelity Investment
Use this form to add or remove a trustee(s) on your Fidelity Account
®
(brokerage) or Fidelity funds account (mutual fund). If you
need more room for information or signatures, use a copy of the relevant page.
Note that if the Trust Taxpayer ID number (TIN or SSN) is changing, this form may not be used; a Fidelity Account Change of
Registration Form or Fidelity Trust Account Application must be used.
1. If naming a successor trustee(s), complete Sections 1, 2A, 3, and 4.
2. If adding a co-trustee(s), complete Sections 1, 2B, 3, and 4.
3. If removing a trustee(s), complete Sections 1, 2C, 3, and 4 and include the document or signature guarantee that is indicated in
Section 2C.
4. If the existing account has margin trading, options trading or trading authority, new forms must be completed to maintain the
features on the account. Visit Fidelity.com to obtain the necessary forms.
Return the completed form to: Fidelity Investments, Account Reregistration Services, P.O. Box 770001, Cincinnati,
OH 45277-0039.
If you have any questions, please call us at 800-544-6666 or visit us at Fidelity.com.
NOTE: Fidelity is unable to use a decedent’s Social Security number for tax reporting. A Taxpayer ID is required.
1
trust information
Trust account number TIN or SSN
Name of trust Date of trust
Name of grantor
Trust permanent address
(no P.O. boxes or C/O) Street
City State ZIP
Trust mailing address
(if different from above) Street
City State ZIP
2
aDD or rEmoVE a trustEE(s)
Complete the information below for each trustee to be added or removed on the account. If there is more than one trustee resigning,
make one or more copies of this Section and have all resigning trustees complete and sign this Section.
A. Naming a successor trustee(s)
I (We), (name[s] of successor trustee[s]), certify that I am (we
are) the successor trustee(s) of the above-named trust in accordance with the terms of the trust instrument.
B. Adding a co-trustee(s)
I (We), (name[s] of co-trustee[s]), certify that I am (we are) the
co-trustee(s) of the above-named trust in accordance with the terms of the trust instrument.
Trustee Certification Form
1.791053.106 018940301
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1.791053.106 018940302
Page 2 of 7
2
aDD or rEmoVE a trustEE(s) (continued)
C. Removing a trustee(s) due to:
Death of trustee (name of deceased trustee) .
Include a copy of the death certificate with this form.
Incapacitation of trustee (name of former trustee) .
Include a letter from the attending physician, on the physician’s letterhead, indicating the incapacitation of the former
trustee, with this form.
Resignation of trustee. I, (name of resigning trustee),
certify that I am resigning as trustee of the above-named trust.
If the value of the trust account is over $10,000, then a signature guarantee is required. A signature guarantee is designed
to protect you and Fidelity from fraud. You should be able to obtain a signature guarantee from a bank, broker-dealer, credit
union (if authorized under state law), securities exchange or association, clearing agency, or savings association. A notary public
cannot provide a signature guarantee.
SIgnature of reSIgnIng truStee PrInt naMe Date (mm/dd/yyyy)
SIgnature guarantee for reSIgnIng truStee
3
trustEE information
Provide the following information for each new trustee on the account. If there are more than two trustees, either make a copy of
Section 3 and have all trustees sign Section 4, or attach a separate piece of paper with their names and required information from this
section, along with the signature of each trustee.
Trustee 1
full legal name
First Name Middle Name Last Name
e-mail address Date of birth (mm/dd/yyyy)
Social Security number or taxpayer ID number
Permanent address
(no P.O. boxes) Street
City State ZIP
Mailing address
(if different from above) Street
City State ZIP
1.791053.106 018940303
3
trustEE information (continued)
Phone numbers: Day Ext. Evening
Countries of Country of
citizenship
U.S. Other(s) tax residence U.S. Other
Employment status: Employed Not employed Retired Occupation
(if retired or not employed, indicate source of income)
Self-Employed — If you are self-employed and your business address is the same as your legal home
address, please initial here that you work out of your home.
Employer’s name
Employer’s address
Street City State ZIP
Associations
Check this box if you are associated with, or employed by, a stock exchange or a member firm of an exchange or FINRA, a
municipal securities dealer, or Fidelity. If you checked the box, obtain and attach the compliance officer’s letter of approval
(“407 letter”) and indicate the name and address of the entity with which you are associated below. Failure to include an
approval letter may delay the processing of your request. We must tell the associated entity that you have applied for this
account. An account approval letter is not required for Fidelity employees.
Check this box if your association is through your employer. (If you checked this box, you are not required to complete the
information below.)
Associated entity name
Address
Street City State ZIP
Check this box if you are a control person or affiliate associated with either (a) another member, (b) a member organization, or
(c) an immediate family/household member of a control person, or are associated with a publicly traded company under SEC Rule
144 (this would include, but is not limited to, a director, 10% shareholder, policy-making officer, and members of the board
of directors).
Trading symbol Company
Page 3 of 7
governMent ID (foreIgn CItIzenS onLY) Identification document must have a reference number and photo. Please attach a photocopy.
Place of birth
City State/Province Country
Immigration status Permanent resident Non-permanent resident Non-resident
Check which type of document you are providing:
Employment Authorization
U.S. driver’s license DHS permanent resident alien card Passport with U.S. visa Document
Passport without U.S. visa*
*Bank name required *Account number required
Foreign national identity document*
*Bank address required *Phone number required
Document number and country of issuance
(Number from the document checked above)
1.791053.106 018940304
Page 4 of 7
3
trustEE information (continued)
receive account Documents online:
For your convenience, certain account documents can be delivered to you electronically. These include account
statements, trade confirmations, prospectuses, and shareholder reports. In addition, as other documents become
available, we will be able to deliver them to you electronically instead of by U.S. mail.
If you do not want electronic delivery of your account documents, you should check off one or more of the boxes below. In order to
enroll in the eDelivery program and begin receiving account documents electronically, you will need to read the Electronic Delivery
Agreement and consent to its terms. You will receive the Electronic Delivery Agreement in an e-mail, unless you select all of the
options below.
I would prefer to receive the following documents by U.S. mail:
Monthly Account Statements
Trade Confirmations and Related Prospectuses
Prospectuses, Shareholder Reports, and
Other Documents
Trustee 2
full legal name
First Name Middle Name Last Name
e-mail address Date of birth (mm/dd/yyyy)
Social Security number or taxpayer ID number
Permanent address
(no P.O. boxes) Street
City State ZIP
Mailing address
(if different from above) Street
City State ZIP
Phone numbers: Day Ext. Evening
Countries of Country of
citizenship
U.S. Other(s) tax residence U.S. Other
governMent ID (foreIgn CItIzenS onLY) Identification document must have a reference number and photo. Please attach a photocopy.
Place of birth
City State/Province Country
Immigration status Permanent resident Non-permanent resident Non-resident
Check which type of document you are providing:
Employment Authorization
U.S. driver’s license DHS permanent resident alien card Passport with U.S. visa Document
Passport without U.S. visa*
*Bank name required *Account number required
Foreign national identity document*
*Bank address required *Phone number required
Document number and country of issuance
(Number from the document checked above)
1.791053.106 018940305
Page 5 of 7
3
trustEE information (continued)
Employment status: Employed Not employed Retired
Occupation
(if retired or not employed, indicate source of income)
Self-Employed — If you are self-employed and your business address is the same as your legal home
address, please initial here that you work out of your home.
Employer’s name
Employer’s address
Street City State ZIP
Associations
Check this box if you are associated with, or employed by, a stock exchange or a member firm of an exchange or FINRA, a
municipal securities dealer, or Fidelity. If you checked the box, obtain and attach the compliance officer’s letter of approval
(“407 letter”) and indicate the name and address of the entity with which you are associated below. Failure to include an
approval letter may delay the processing of your request. We must tell the associated entity that you have applied for this
account. An account approval letter is not required for Fidelity employees.
Check this box if your association is through your employer. (If you checked this box, you are not required to complete the
information below.)
Associated entity name
Address
Street City State ZIP
Check this box if you are a control person or affiliate associated with either (a) another member, (b) a member organization, or
(c) an immediate family/household member of a control person, or are associated with a publicly traded company under SEC
Rule 144 (this would include, but is not limited to, a director, 10% shareholder, policy-making officer, and members of the
board of directors).
Trading symbol Company
receive account Documents online:
For your convenience, certain account documents can be delivered to you electronically. These include account statements, trade con-
firmations, prospectuses, and shareholder reports. In addition, as other documents become available, we will be able to deliver them
to you electronically instead of by U.S. mail.
If you do not want electronic delivery of your account documents, you should check off one or more of the boxes below. In order to
enroll in the eDelivery program and begin receiving account documents electronically, you will need to read the Electronic Delivery
Agreement and consent to its terms. You will receive the Electronic Delivery Agreement in an e-mail, unless you select all of the
options below.
I would prefer to receive the following documents by U.S. mail:
Monthly Account Statements
Trade Confirmations and Related Prospectuses
Prospectuses, Shareholder Reports, and
Other Documents
4
trustEE CErtifiCations anD siGnaturEs
By signing below, the undersigned trustee(s) acknowledge(s) and agree(s) to the following:
a. Fidelity (“Fidelity” and/or “you” means Fidelity Brokerage Services LLC, National Financial Services LLC,
Fidelity Service Company, Inc., Fidelity Management Trust Company, Fidelity Distributors Corporation, and
their affiliates) has the authority to accept orders and other instructions relative to the trust accounts identified
herein from those individuals or entities listed in Section 3. Trustee(s) may execute any documents on behalf of
the trust that you may require. By signing this form, the trustee(s) hereby certifies(y) that you are authorized to follow the
instructions of any trustee and to deliver funds, securities, or any other assets in the account to any trustee or on any trustee’s
instructions, including delivering assets to a trustee personally. Fidelity, in its sole discretion and for its sole protection, may
require the written consent of any or all trustees prior to acting on the instructions of any trustee. Applying for a trust account is
also considered to be a statement that all trustees certify that Fidelity can rely on instructions from any one trustee to represent
the unanimous consent of all trustees for actions taken on this account.
b. The trust exists under applicable state laws.
c. There is(are) no trustee(s) of the trust other than those listed in Section 3 or included with this form.
d. Should only one person execute this certification, it is a representation that the signer is the sole trustee. Where applicable, plural
references in this certification shall be deemed singular.
e. We, the trustees, have the power under the trust and applicable law to enter into the transactions and issue the instructions that
we make in this account. Such power may include, without limitation, the authority to buy, sell (including short sales), exchange,
convert, tender, redeem, and withdraw assets (including delivery of securities to and from the account), and to trade securities on
margin or otherwise (including the purchase and/or sale of option contracts) for and at the risk of the trust, provided, however,
that any such power must be permitted under the applicable account agreements or prospectus governing such accounts. We
understand that all orders and transactions will be governed by the terms and conditions of all other account agreements appli-
cable to this account.
f. We, the trustees, jointly and severally, indemnify you and hold you harmless from any claim, loss, expense, or other liability for
effecting any transactions, and acting upon any instructions given by the trustees. We, the trustees, certify that any and all trans-
actions effected and instructions given on this account will be in full compliance with the trust.
g. We, the trustees, agree to inform you in writing of any change in the composition of the trustees, or any other event that could
alter the certifications made above.
h. We, the trustees, agree that any information given on this Trustee Certification Form is subject to verification. If this form applies
to a brokerage account, we authorize Fidelity to obtain a credit or other financial responsibility report on any of us at any time.
Upon written request, Fidelity will provide the name and address of the credit reporting agency used.
i. We represent and warrant that the terms of this form have not been changed and are identical to the terms as originally set forth
by Fidelity. We acknowledge that any alteration of the form’s original terms shall be null and void and we shall be bound by the
terms of the original form as set forth by Fidelity. We understand and acknowledge that the above-referenced agreement may be
terminated in the event that Fidelity or any of its agents or affiliates has reasonable grounds to believe the foregoing is untrue, or
the form has been altered.
j. By not checking the box for Securities Industry Affiliations or Public Company Affiliations, we represent and warrant that we are
not affiliated with, or employed by, a stock exchange or a broker-dealer, or we are not a control person or affiliate of a public
company under SEC Rule 144 (such as a director, 10% shareholder, or policy-making officer), or an immediate family member or
household member of such a person.
k. We, the trustees, certify to Fidelity that the trust has not been revoked, modified, or amended in any manner that would cause the
representations contained in this trust certification to be incorrect.
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1.791053.106 018940306
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404060.6.0 Fidelity Investments U163-FORM-1011
Account Reregistration Services, P.O. Box 770001, Cincinnati, OH 45277-0039 1.791053.106
Fidelity Brokerage Services LLC, Member NYSE, SIPC
1.791053.106 018940306
4
trustEE CErtifiCations anD siGnaturEs (continued)
CertIfIeD to fIDeLItY BY truStee(S) — all trustees must sign and date below. all trustee signatures
must be guaranteed if applicable.
If you are removing a trustee and the value of the trust is greater than $10,000, a signature guarantee of the successor
trustee(s) signature is required. If you are adding a co-trustee and the value of the trust is greater than $100,000, a signature
guarantee of the current trustee(s) signature is required. A signature guarantee is designed to protect you and Fidelity from fraud.
You should be able to obtain a signature guarantee from a bank, broker, broker-dealer, credit union (if authorized under state law),
securities exchange or association, clearing agency, or savings association.
SIgnature of truStee 1 PrInt naMe Date (mm/dd/yyyy)
SIgnature of truStee 2 PrInt naMe Date (mm/dd/yyyy)
SIgnature guarantee (TRUSTEE 1) SIgnature guarantee (TRUSTEE 2)
