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Transfer/Rollover/Exchange Form

Instructions: Use this form to move assets to your Fidelity employer-sponsored retirement account from a previous investment pro- vider. You may also use this form to consolidate multiple employer-sponsored retirement accounts currently at Fidelity. If you do not have a retirement account with Fidelity, you must also complete an Account Application/Enrollment Form or when available enroll online at www.mysavingsatwork.com. If your current employer does not offer a retirement plan record kept by Fidelity, your employer needs to establish a retirement plan prior to your vendor or contract exchange, or rollover to a Fidelity account. An incomplete form may delay the processing of your request. Use a separate form for each investment provider.

Unless otherwise instructed by your employer, please return this vendor or contract exchange/rollover form in the postage-paid

Return to:

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

Fidelity Investments P.O. Box 770002

Fidelity Investments 100 Crosby Parkway, Mailzone KC1E

Cincinnati, OH 45277-0090

Covington, KY 41015

envelope provided OR

Questions? Call Fidelity Investments at 1-800-343-0860 or for the hearing impaired (TTY) 1-800-259-9743, Monday through Friday,

8 a.m. to midnight Eastern time (except for New York Stock Exchange holidays), for assistance with completing this form.

1. YOUR INFORMATION Please use a black pen and print clearly in CAPITAL LETTERS.

Social Security #:

Date of Birth:

First Name:

Last Name:

Mailing Address:

City:

State:

Zip:

Daytime Phone:

Evening Phone:

E-mail:

2. INVESTMENT PROVIDER YOU ARE MOVING MONEY FROM Name of investment provider you are moving money from

Please include a copy of your most recent account statement from your investment provider. Provider Street Address:

City:

State:

Zip:

Provider Phone:

Ext:

Please contact your previous investment provider to see if additional paperwork is required. Use a separate form for each investment provider.

5VFITSTAS002N

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