Fidelity Transfer / Rollover Form (Page 3 of 4) in pdf

4. ACCOUNT INSTRUCTIONS

Please indicate into which investment options you would like your assets to be invested. If no investment options are selected, or

the investment options selected are not available in your plan, the assets will be allocated to your current account allocations. If a

current account allocation can not be identified, your assets will be defaulted according to your plan provisions.

Please invest my assets in the following investment options (refer to the prospectus for the full name of the investment option):

Investment Options

Please use whole percentages

Fund Code:

Fund Name:

Percentage:

Total = 100%

5. AUTHORIZATION, APPROVAL, AND ACCEPTANCE

Individual Authorization

By executing this Form

• I hereby agree to the terms and conditions stated in this Form and certify that I am requesting a rollover or transfer of my retirement plan

assets in accordance with applicable IRS and plan rules.

• I certify under the penalties of perjury that my Social Security number on this form is correct.

• I acknowledge that I have read the prospectus(es) for any mutual fund in which I invest and agree to the terms.

• I hereby direct the investment provider identified on this form to liquidate the designated amount of the account(s) listed on this form, and

to release the proceeds to my account under my employer’ s plan, except to the extent my current employer or any of my former employers

prohibit such release. In the event of such prohibition, I hereby direct said investment provider to retain the nontransferable portion of my

account(s) in a separate account or contract and to release the remainder.

• I hereby agree that if my assets will be sent to Fidelity in installments, the first installment will be invested according to my instructions on

this form. All subsequent installment payments as well as any residual balances not received within 30 days will be invested according to

my current investment elections at the time my assets are received by Fidelity.

• I understand that I may designate a beneficiary for my assets accumulated under the plan and that if I choose not to designate a beneficiary,

distributions will be made according to the plan document or, if applicable, the Fidelity Investments Section 403(b)(7) Individual Custodial

Account Agreement.

For 403(b)-to-403(b) transfers

• I understand that any balances I am transferring from a 403(b)(1) annuity into a 403(b)(7) custodial account will be subject to more

restrictive withdrawal provisions.

• I direct Fidelity to treat all monies as employer pretax contributions made subsequent to 12/31/88 unless my prior investment provider

provides Fidelity with account balances as of 12/31/88 and post-1988 salary reduction contributions.

• I direct Fidelity to treat the entire balances as subject to minimum distribution requirements unless my prior investment provider provides

Fidelity with account balances as of 12/31/86.

• I direct Fidelity to allocate the entire balance to the most restrictive source in the current employer’ s plan unless my prior investment

provider provides Fidelity with the sources of the transferred amount under the previous plan.

Your Signature:

Date:

Please be sure to sign.

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Fidelity Transfer / Rollover Form Page 3