Transcription of Fidelity Investment-Only Retirement Account Contribution …
1 Questions? Call 1-800-544-5373, option 1 of 2007420101 Fidelity Investment-Only Retirement Account Contribution FormUse this form to allocate contributions to your Fidelity Investment-Only Retirement Account (s) (also known as the Fidelity Non-Prototype Retirement Account ). Type on screen or fill in using CAPITAL letters and black ink. If you need more room for information, use a copy of the relevant to Know An Investment-Only Retirement Account provides an investment vehicle for qualified Retirement plan assets. Fidelity does not provide trustee, recordkeeping, tax-withholding, or tax-reporting services for this type of Account . Do NOT use this form to purchase individual securities other than mutual funds. Visit or contact a Fidelity representative at 1-800-544-6666 to place a trade after this deposit has posted to your Account (s).
2 All deposits must meet mutual fund eligibility and minimum investment requirements as described in the applicable fund prospectus or fact kit. You cannot invest in accounts that are restricted. If purchasing a new fund, you must have read the prospectus and agree to its terms. All deposits may be subject to a four business day clearing period. only checks payable to Fidelity Investments or to the Fidelity fund name will be accepted. Fidelity does not accept third-party checks. You will want to keep a copy of all completed forms for your records. Make checks payable as follows: Brokerage Accounts Fidelity Investments Mutual Fund Accounts Fidelity Fund Name ( , Fidelity Government Cash Reserves)1. Plan and Trust InformationEmployer Name ( , Company Name)Plan Tax Identification NumberTrustee NameDaytime PhoneExtension2.
3 Deposit Information Indicate below how to allocate contributions for each Plan Participant Participant NamePlan Participant Account NumberFidelity Fund Name or SymbolAmount$.2 Plan Participant NamePlan Participant Account NumberFidelity Fund Name or SymbolAmount$.3 Plan Participant NamePlan Participant Account NumberFidelity Fund Name or SymbolAmount$.Brokerage accounts: Investments will be placed in the core posi-tion unless you specify mutual fund position(s). Do NOT list individual securities other than mutual funds on this form . See instructions in the Helpful to Know section above if you want to purchase individual Fund only accounts: Investments will be placed in the mutual fund position(s) as specified. only Fidelity mutual funds may be continues on next page. 2 of 2007420102On this form , Fidelity means Fidelity Brokerage Services LLC and its affiliates.
4 Brokerage services are provided by Fidelity Brokerage Services LLC, Member NYSE, SIPC. (11/15)Make Checks Payable to: Fidelity Investments or to the Fidelity fund nameQuestions? Call 1-800-544-5373, option postage-paid envelope OR mail to:Regular mail Fidelity Investments Box 770001 Cincinnati, OH 45277-0048 Overnight mail Fidelity Investments 100 Crosby Parkway, KC1H Covington, KY 410154 Plan Participant NamePlan Participant Account NumberFidelity Fund Name or SymbolAmount$.5 Plan Participant NamePlan Participant Account NumberFidelity Fund Name or SymbolAmount$.6 Plan Participant NamePlan Participant Account NumberFidelity Fund Name or SymbolAmount$.7 Plan Participant NamePlan Participant Account NumberFidelity Fund Name or SymbolAmount$.8 Plan Participant NamePlan Participant Account NumberFidelity Fund Name or SymbolAmount$.
5 9 Plan Participant NamePlan Participant Account NumberFidelity Fund Name or SymbolAmount$.10 Plan Participant NamePlan Participant Account NumberFidelity Fund Name or SymbolAmount$.
