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.

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:

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