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

6. PLAN AUTHORIZATION

Please check with your employer to determine if you need to have this transfer/rollover approved by your employer, a

trustee or a custodian. If no authorization is required, please skip this section.

I hereby certify that the employee-directed investment transfer(s)/rollover(s) identified above is(are) in accordance with the

plan’ s provisions.

Employer

Trustee

Authorized Signature:

Date:

TRANSFER/ROLLOVER CHECKLIST

Here’ s a checklist to ensure that your request is in good order.

Please remember to:

• Complete all sections

• Sign the form

• Indicate the amount or percent of your transfer or rollover

• Obtain the Employer Signature (if required)

• Provide the Previous Investment Provider’ s Address

• Provide the Previous Investment Provider’ s Form (if required)

• Return this form in the enclosed postage-paid envelope OR mail to

Fidelity Investments, P.O. Box 770002, Cincinnati, OH 45277-0090

Questions ?

For questions about:

Enrolling

1-888-8ENROLL (1-888-836-7655)

Transferring workplace retirement savings assets

1-800-427-6139

Existing Fidelity accounts

1-800-343-0860

Text Telephone Service Line (TTY) 1-800-259-9743 – For callers with speech and hearing impairments, this service offers

direct access to a Fidelity Retirement Services Specialist and is available Monday through Friday from 8:00 A.M. to midnight ET.

TRANSFERRING INVESTMENT PROVIDER

INFORMATION REQUESTED OF TRANSFERRING INVESTMENT PROVIDER

Please provide the following information on the check:

• FBO • Social Security Number

Please make the check payable to Fidelity Management Trust Company and return it to:

Fidelity Investments, P.O. Box 770002, Cincinnati, OH 45277-0090

In addition please provide the following either on the check or by separate letter:

1. For hardship distribution restriction:

• Account balance as of 12/31/88

• Post-1988 salary reduction contributions

• Post-1988 non-salary reduction contributions (e.g., employer monies)

2. For minimum distribution requirements 403(b) plan transfers:

• Account balance as of 12/31/86

3. Please provide the dollar amount or percentage of the breakdown of each money type being transferred.

• Portion of transfer — employee pre-tax

• Portion of transfer — employee after-tax

• Portion of transfer — employer matching

For Internal Use Only

Fidelity Investments hereby agrees to accept the transfer/rollover described above for deposit in the 403(b)/401(a)/401(k)/ 457(b)

Account established on behalf of the individual.

Authorized Signature:

Date:

1.754184.103

325046

Fidelity Investments Institutional Operations Company, Inc.

Page 4

Fidelity Transfer / Rollover Form Page 4

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