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Questions? Go to Fidelity.com/costbasis or call 1-800-544-6666.
Cost Basis Update Form
Use this form to provide Fidelity with your adjusted tax basis information (often referred to as “cost basis” information) for certain
individual securities or mutual fund positions in your non-retirement account. You may also use this form to change certain cost basis
information that you previously provided to Fidelity. For your convenience, cost basis information may also be updated on Fidelity.com.
Cost basis for unknown positions may be updated on the Portfolio Positions page, by clicking the Enter Cost link in the Cost Basis column.
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.
Cost basis on securities purchased at Fidelity cannot be changed by customers. Cost basis provided by another broker for transferred securities may be changed for noncovered securities and may not be changed by customers if the prior broker indicates that
the shares are covered under the cost basis regulations.
Helpful to Know
•W
e will update our cost basis information records with the inforperiod of time. We encourage you to review IRS Publication 550,
mation you provide here and report it on future statements as
Investment Income and Expense (Including Capital Gains and
“customer provided.”
Losses), or consult your tax advisor for assistance. Fidelity does
not provide tax advice and cannot assist you with cost basis cal• The IRS requires Fidelity to report cost basis information on
culations for “unknown” shares.
covered securities. A security is covered if it is a stock purchased
on or after 1/1/2011 or it is a mutual fund share purchased on or • Tax lot designations can be accepted until settlement. Regulations
after 1/1/2012. Cost basis information on noncovered securities
prohibit us from accepting lot designations beyond the settlement
generally is not reported to the IRS.
date of the transaction, which varies depending on the security.
Settlement on transfers is same day.
• Calculating your cost basis for tax purposes can be complicated,
particularly if you have purchased and sold shares over a long
1. Account Owner(s)
Name
Fidelity Account Number
Additional Owner/Authorized Individual Name
Phone numbers may be
used if we have questions but will not be
used to update your
account information.
Evening Phone
Daytime Phone
Extension
2. Cost Basis Information
Complete the table that follows, attaching additional pages as necessary. If you acquired shares of a particular security at different times
(through dividend reinvestment, for example), identify each acquisition separately. If you are providing tax basis information for mutual
fund holdings and you intend to report any gains or losses to the IRS using the average cost method, it may be more convenient to write
the information for all shares on one line. Note, however, that Fidelity may be unable to determine the holding period if you choose this
approach. See the Fidelity ABC Fund example on the next page.
Security or Fund Name: The detailed name of the individual security or mutual fund you own.
Symbol: The symbol of the individual security or mutual fund as shown on your Fidelity statement. If you do not hold the fund in a Fidelity
brokerage account, leave this column blank.
Number of Shares in Tax Lot: The number of shares for which you are providing cost basis information. For individual securities, if you acquired
shares of the same investment at different times, please provide us with the information in detail (see the XYZ Corporation example). For mutual
funds, if you acquired shares of the same fund at different times, you can provide us with the information either in detail or in aggregate.
Date Acquired: Generally, the date the individual security or mutual fund came into your possession (i.e., trade date). For mutual funds, if
you acquired shares of the same fund at different times and you choose to aggregate the information, write “various” in this column. You
may write “various” in this column for shares held for more than one year. For shares held one year or less, you must provide the detail for
each purchase.
Total Cost Basis of Lot: The dollar amount that you paid to acquire the shares indicated, including any commissions, purchase charges, or
other fees properly added to the original cost basis, as well as any other required adjustments due to corporate actions or the application of
special rules.
Cost Basis Information continues on next page.
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009270201
2. Cost Basis Information, continued
brokerage
accounts only
Symbol
Number of
Shares in
Tax Lot
Date Acquired
MM/DD/YYYY
Total Cost Basis
of Lot
XYZ Corporation or XYZ Mutual Fund
XYZ
500
05/16/1988
$5,019.95
XYZ Corporation or XYZ Mutual Fund
XYZ
100
11/13/1991
$2,519.95
FABCX
847,419
various
$27,625.86
Security or Fund Name
Fidelity ABC Fund (Aggregate Example)
3. Tax Lot Designation
Complete the following tables to designate specific lot depletion for a sale or transfer, attaching additional pages as necessary. The total
share amount depleted (left columns) must equal the total amount of the purchase lots targeted (right columns). Fidelity’s default disposal
method is First In, First Out (FIFO) if alternative instructions are not received. Other default disposal methods are available, which may limit
the need to complete this form. Per the IRS regulations outlined in Publication 550, we are unable to accept specific share instructions
beyond settlement date.
SELL:
TARGET LOTS:
DATE MM/DD/YYYY
SHARES
PRICE PER SHARE
DATE MM/DD/YYYY
Example:
05/01/2008
SHARES
BASIS PER SHARE
Examples:
400.000
$20.075
VS.
03/02/2006
100.000
$17.500
VS.
06/15/2007
300.000
$18.925
VS.
VS.
VS.
VS.
VS.
VS.
VS.
VS.
VS.
VS.
VS.
Form continues on next page.
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009270202
3. Signatures and Dates
ALL Account owners must sign and date.
By signing below, you:
• Authorize and instruct Fidelity to include the • Agree that Fidelity will not be liable for any • Understand and agree that if you have quesinformation you have provided above on
loss or damage arising out of your use of the
tions about your individual tax situation, you
any of your statements.
information.
will consult a tax advisor.
• Understand and agree that Fidelity will not
• Understand that the information will be
• Acknowledge that tax information contained
verify the accuracy of the information you
denoted on your statements as “customer
herein is not intended or written to be
have provided.
provided.”
used, and it cannot be used by you, for the
purpose of avoiding penalties that may be
• Acknowledge that Fidelity does not make
• Acknowledge that Fidelity does not provide
imposed on taxpayers.
any representation or give any advice
tax or legal advice.
regarding your use of the information.
Print Owner Name
SIGN
Owner Signature Date
mm dd yyyy
Date
mm dd yyyy
Print Additional Owner/Authorized Individual Name
SIGN
Additional Owner/Authorized Individual Signature Did you sign the form? Send the ENTIRE form and any attachments
to Fidelity Investments.
Questions? Go to Fidelity.com/costbasis or call 1-800-544-6666.
Use postage-paid envelope, drop off at a Fidelity
Investor Center, OR deliver to:
Regular mail
Overnight mail
Fidelity Investments
Fidelity Investments
P.O. Box 770001
100 Crosby Parkway KC1K
Cincinnati, OH 45277-0001 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. 461081.3.0 (07/14)
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