Self-Employed 401(k) — Contribution Remittance Form

Questions? Go to or call 1 of 1032610101 Self-Employed 401(k) Contribution Remittance FormUse 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 check(s) payable to Fidelity Investments and mail to: Regular mail: Fidelity Investments, 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.

Questions? Go to Fidelity.comsmallbusiness or call 00-343-34. 1.785683.106 Page 1 of 1 032610101 Self-Employed 401(k) — Contribution Remittance Form Use this form to submit contribution deposits to your Fidelity Self-Employed 401(k) Plan account(s).

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