Beneficiaries Defined Contribution Retirement Plan

1 Print Reset Save Questions? Go to or call 800-343-3548. Beneficiaries Defined Contribution Retirement Plan Use this form to add or change the Beneficiaries of your Fidelity Self-Employed 401(k), Profit Sharing, or Money Purchase Plan account(s). Do NOT use for any other type of account. Type on screen or print out and fill in using CAPITAL letters and black ink. If you need more room for information, make a copy of the relevant page. Helpful to Know Y ou may want to review this document with a tax, Y ou can change Beneficiaries any time at financial, or legal advisor. beneficiary. To add or change Beneficiaries on other This form cancels any existing beneficiary information.

2 Types of accounts, go to Be sure this form includes ALL Beneficiaries you want on If you are married, and you designate anyone other than the account(s). your spouse as beneficiary, you must provide a notarized signature of your spouse in Section 5. 1. Account Owner Name This phone number may be used if we have questions, but will not Daytime Phone Extension be used to update your account information. Married Not Married 2. Accounts Included To indicate different Beneficiaries for different accounts, make copies of this form. List all accounts you Retirement Plan Account Number Retirement Plan Account Number Retirement Plan Account Number want this form to apply to.

3 3. Beneficiaries Primary Beneficiaries For each beneficiary Spouse Name If naming spouse as a beneficiary, do so here. you list, check a beneficiary type and Non-Spouse provide all information, Trust Social Security or Taxpayer ID Number Date of Birth/Trust MM DD YYYY Share Percentage including the full Per stirpes first and last name as Other Entity %. evidenced by a Name government-issued, unexpired document Non-Spouse ( , driver's license, Trust Social Security or Taxpayer ID Number Date of Birth/Trust MM DD YYYY Share Percentage passport, permanent Per stirpes resident card). Other Entity %. If you outlive a beneficiary and you Name want that beneficiary's Non-Spouse share to go to his or her Trust descendants, check Social Security or Taxpayer ID Number Date of Birth/Trust MM DD YYYY Share Percentage Per stirpes Per stirpes.

4 Other Entity %. Name Non-Spouse Trust Social Security or Taxpayer ID Number Date of Birth/Trust MM DD YYYY Share Percentage Per stirpes Other Entity %. Total must add up to 100%. 0%. Beneficiaries continues on next page. Page 1 of 3 007040501. 3. Beneficiaries , continued Contingent Beneficiaries Contingent Beneficiaries Spouse Name If naming spouse as a beneficiary, do so here. receive assets only if no primary beneficiary Non-Spouse survives you. Trust Social Security or Taxpayer ID Number Date of Birth/Trust MM DD YYYY Share Percentage Per stirpes Do NOT list any primary Other Entity %. Beneficiaries here. If you outlive a Name beneficiary and you Non-Spouse want that beneficiary's Trust share to go to his Social Security or Taxpayer ID Number Date of Birth/Trust MM DD YYYY Share Percentage Per stirpes or her descendants, Other Entity %.

5 Check Per stirpes.. Name Non-Spouse Trust Social Security or Taxpayer ID Number Date of Birth/Trust MM DD YYYY Share Percentage Per stirpes Other Entity %. Name Non-Spouse Trust Social Security or Taxpayer ID Number Date of Birth/Trust MM DD YYYY Share Percentage Per stirpes Other Entity %. 0%. Total must add up to 100%. 4. Signature and Date Account owner or authorized individual must sign and date. By signing below, you: Affirm that the beneficiary information A gree that Fidelity has no obligation A gree that if your beneficiary allocation provided on this form replaces any prior to locate or notify any beneficiary or to totals at least 99%, but less than 100%.

6 Beneficiary information that may be on independently verify any information ( , 3 named Beneficiaries are each record for the indicated account(s). submitted by any person claiming an assigned a 33% interest in the account), Acknowledge that, if you check per interest in your account. Fidelity will assign the unallocated remain- stirpes, that any share otherwise payable Acknowledge that if you do not provide der to the first named beneficiary. to a beneficiary shall instead be paid to percentages, the account will be divided Agree that when your assets are distrib- that beneficiary's surviving descendants by equally among primary or contingent ben- uted to your Beneficiaries , fractional shares right of representation if the original bene- eficiaries, as applicable.

7 That cannot be distributed in accordance ficiary does not survive the account owner. Acknowledge that if you do not properly with your instructions will instead be given Acknowledge that per stirpes creates a name a beneficiary, or no beneficiary sur- to the beneficiary receiving the largest per- category of Beneficiaries (for example, the vives you, your beneficiary will be your centage of the account's assets or, if each children of a beneficiary), and therefore spouse or, if you are not married, your beneficiary is receiving an equal percent- may end up including individuals not yet estate in accordance with the rules of suc- age, to the last paid beneficiary.

8 Born or adopted. cession in the Plan Document. Acknowledge that Fidelity has no respon- Acknowledge that listing Beneficiaries Acknowledge that, if you are married and sibility for the application of assets by name does NOT create a category of you designate anyone other than your distributed to Beneficiaries . Beneficiaries , and that if you later want to spouse as beneficiary, your designation include other Beneficiaries , you will need cannot be accepted without your spouse's to submit a new beneficiary form. notarized signature in Section 5. PRINT OWNER/AUTHORIZED INDIVIDUAL NAME. OWNER/AUTHORIZED INDIVIDUAL SIGNATURE DATE MM/DD/YYYY.

9 X X. SI GN. Form continues on next page. Page 2 of 3 007040502. 5. S. pouse's Consent Notarized signature required if spouse is not the only primary beneficiary. By signing below, you: agree to the designation of the beneficiary(ies) on this form understand that you are allowing those beneficiary(ies) to receive assets that would otherwise be paid to you PRINT SPOUSE NAME. SPOUSE SIGNATURE DATE MM/DD/YYYY. X X. SIGN. Important Note: CA Notaries are permitted to submit a separate page notary document. If used, it must identify the document being notarized. Notice to CA Residents: A Notary Public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document.

10 Certificate of Acknowledgement of Notary Public Must be a Notary. Foreign notary or consular seals may NOT be substituted. State of , in the County of , subscribed and sworn to before me by the above-named individual who is personally known to me or who has produced as identification, that the foregoing statements were true and accurate and made of his/her own free act and deed, on / / . PRINT NOTARY NAME NOTARY SEAL / STAMP. NOTARY SIGNATURE DATE MM/DD/YYYY. X X. SIGN. My commission expires / / . Did you sign the form? Send the ENTIRE form to Fidelity. You will Regular mail Overnight mail receive a Revised Account Profile confirming your updates.