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Would you like the assets invested in your current investment selection? If “Yes” is selected, your assets will be allocated to your current investment selection on file with Fidelity. If you do not select “Yes,” please list the fund names, fund codes (if known) and percentages. Please ensure that the percentages equal 100%. Please list additional funds on a separate page and attach it to this form.

Fund Name: List the Fund Name(s) you want your assets credited to. Fund Code: Provide the four-digit Fund Code(s) (if known). Percentage: Please ensure that the percentages listed equal 100%.

Note: If the funds selected are unclear, unavailable, or less than 100%, the percentages allocated to those funds and/or any unallocated percentage will be defaulted to the investment option specified in the agreement currently in place with Fidelity for the P l a n . I f t h e p e r c e n t a g e s l i s t e d e x c e e d 1 0 0 % , t h e e n t i r e a m o u n t w i l l b e d e f a u l t e d , a s d e s c r i b e d a b o v e . 6. EMPLOYER PLAN ACCEPTANCE

Employer Authorized Signature: An authorized signature from the employer that sponsors your Fidelity retirement account may be required. To verify if this section needs to be signed, contact your Human Resources office or Fidelity at 1-800-343-0860 or for the hearing impaired (TTY) 1-800-259-9743.


Your Signature: Please read the legal information provided in this section and then sign the form. We are unable to process your request without your signature.

Transfer/Rollover/Exchange Form Checklist:

Here is a checklist to ensure that your request is in good order. Please remember to:

Include your most recent account statement from the Previous Investment Provider

Indicate the amount or percentage of money you are moving to Fidelity

Obtain the Employer Authorized Signature (contact your Human Resources office or Fidelity to verify if this is required)

Sign in Section 7 of the form

Return this form in the enclosed postage-paid envelope OR

Fidelity Investments P.O. Box 770002

Fidelity Investments 100 Crosby Parkway, Mailzone KC1E

Cincinnati, OH 45277-0090

Covington, KY 41015

Return to:

If you are sending this using an overnight delivery service, please send to this address:

Please contact your previous investment provider to see if additional paperwork is required.

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