Self-Employed 401(k) — Contribution Remittance Form

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Self-Employed 401(k)--Contribution Remittance Form

Use this form to submit contribution deposits to your Fidelity Self-Employed 401(k) Plan account(s). Type on screen or fill in using CAPITAL letters and black ink. If you need more room for information, make a copy of this form.

Make check(s) payable to Fidelity Investments and mail to: ? Regular mail: Fidelity Investments, P.O. Box 770001, Cincinnati, OH 45277-0003 ? Overnight mail: Fidelity Investments, 100 Crosby Parkway, KC1H, Covington, KY 41015

Helpful to Know

? Be sure to indicate below how to allocate contributions for each plan participant to the applicable contribution sources: Employee 401(k) and/or Employer Profit Sharing Contributions.

? If we are unable to allocate contributions to the sources indicated, we will deposit them as Employer Profit Sharing Contributions, and will then contact you on how to resolve them.

? Note: It is your responsibility to separately account for each of the two different contribution types to ensure that applicable annual

limits are not exceeded. Refer to smallbusiness for applicable limits.

? Contributions will be deposited in each participant's core account. Participants can place a trade in their account by going to or by calling Fidelity.

? Please keep a copy of your completed contribution remittance form for your records.

1. Employer Information

Employer Name (i.e., Company Name)

Employer Tax ID Number

Plan Administrator

Daytime Phone

Extension

2. Contribution Information All deposits may be subject to a four-business-day clearing period.

Employee Name

Fidelity Account Number Employee 401(k) Contribution Employer Profit Sharing Total Contribution Current Year (CYP) Prior Year (PYP) Contribution (CCR)*

$

$

$

$ 0.00

$

$

$

$ 0.00

$

$

$

$ 0.00

*To the extent applicable, include any safe harbor nonelective contributions.

Total $ 0.00

3. Authorization

By signing below, you:

? Understand that you are required to comply with applicable contribution limits and deadlines.

? Hereby authorize Fidelity Brokerage Services LLC ("Fidelity") to deposit the dollar amounts to the designated account(s), as instructed above.

? Understand that it is your responsibility to ? Agree to fully indemnify and hold Fidelity

allocate contributions to the appropriate

and its affiliates harmless for any liability

employee and contribution source correctly. that may arise from Fidelity acting upon

Failure to clearly designate a contribution

your instructions.

type may result in the entire check being

returned to you for further instructions, for

which Fidelity will not be responsible for

delay(s) in contributions.

PRINT PLAN ADMINISTRATOR OR EMPLOYER NAME

SIGN

PLAN ADMINISTRATOR OR EMPLOYER SIGNATURE

X

DATE MM/DD/YYYY

X

On this form, "Fidelity" means Fidelity Brokerage Services LLC and its affiliates. Brokerage services are provided by Fidelity Brokerage Services LLC, Member NYSE, SIPC. 390265.5.0 (06/17)

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