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3. ACCOUNT(S) OR CONTRACT(S) TO MOVE

Please provide information about the account(s)/contract(s) you wish to move to Fidelity. If no account or contract numbers are provided, we will use your Social Security or U.S. Tax ID number to request the assets to be moved.

Please make additional copies of this page and the next page if you have more than two accounts/contracts to move.

3A. FIRST ACCOUNT (if more than one account, please complete section 3B in addition to section 3A).

1. Account/Contract #:

and Type: (select one)

403(b)

Include Roth 403(b) balance

401(a)/(k)

Include Roth 401(k) balance

457(b) governmental

IRA

2. Please check the box that most accurately reflects the transaction that you are requesting. Note that your selection will dictate how we process this transaction. Please read Section 4 of the instructions for more details.

The Same Employer as my Employer Plan with Fidelity.

A Previous Employer. For 403(b) and 401(a)/(k) plans. Previous Employer Name:

A Rollover IRA. A Traditional IRA or SEP IRA.

3. Liquidation Amount (select one)

Full Liquidation/100%

Partial Liquidation

% OR $

Unless otherwise specified, I request the cur- rent investment provider to liquidate 100% of my account.

3B. SECOND ACCOUNT (if applicable).

1. Account/Contract #:

and Type: (select one)

403(b)

Include Roth 403(b) balance

401(a)/(k)

Include Roth 401(k) balance

457(b) governmental

IRA

2. Please check the box that most accurately reflects the transaction that you are requesting. Note that your selection will dictate how we process this transaction. Please read Section 4 of the instructions for more details.

The Same Employer as my Employer Plan with Fidelity.

A Previous Employer. For 403(b) and 401(a)/(k) plans. Previous Employer Name:

A Rollover IRA. A Traditional IRA or SEP IRA.

3. Liquidation Amount (select one)

Full Liquidation/100%

Partial Liquidation

% OR $

Unless otherwise specified, I request the cur- rent investment provider to liquidate 100% of my account.

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