Self-Employed 401(k) — Contribution Remittance Form

1 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.

2 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 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 Employer InformationEmployer Name ( , Company Name)Employer Tax ID NumberPlan AdministratorDaytime PhoneExtension2. Contribution Information All deposits may be subject to a four-business-day clearing NameFidelity Account NumberEmployee 401(k) ContributionEmployer Profit Sharing Contribution (CCR)*Total ContributionCurrent Year (CYP)Prior Year (PYP)$$$$$$$$$$$$*To the extent applicable, include any safe harbor nonelective $3. AuthorizationBy signing below, you: Understand that you are required to comply with applicable Contribution limits and deadlines.

3 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 allocate contributions to the appropriate employee and Contribution source correctly. Failure to clearly designate a Contribution 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 . Agree to fully indemnify and hold fidelity and its affiliates harmless for any liability that may arise from fidelity acting upon your PLAN ADMINISTRATOR OR EMPLOYER NAMEPLAN ADMINISTRATOR OR EMPLOYER SIGNATURE DATE MM/DD/YYYYSIGNX XOn this form , fidelity means fidelity Brokerage Services LLC and its affiliates. Brokerage services are provided by fidelity Brokerage Services LLC, Member NYSE, SIPC. (06/17)