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Go to [Fidelity.com/smallbusiness](Fidelity.com/smallbusiness) or call 800-343-3548.  \nSelf-Employed 401(k)/Roth Self-Employed 401(k)—  \nContribution Remittance Form  \nUse this form to submit contribution deposits to your Fidelity Self-Employed 401(k) Plan or Roth Self-Employed 401(k) Plan account(s). Type on screen or fill in using CAPITAL letters and black ink. If you need more room for information, make a copy of this form. Make check(s) payable to Fidelity Investments and mail to:  \n• Regular mail: Fidelity Investments, PO Box 770001, Cincinnati, OH 45277-0003  \n• Overnight mail: Fidelity Investments, 100 Crosby Parkway, KC1H, Covington, KY 41015  \nHelpful to Know  \n• Roth 401(k) contributions are nondeductible, and once deposited as Roth, they cannot be changed to traditional 401(k) contributions.  \n• Be sure to indicate below how to allocate contributions for each plan participant to the applicable contribution sources: Employee 401(k), Roth 401(k), and/or Employer Profit Sharing Contributions.  \n• Note: It is your responsibility to separately account for each of the two different contribution types to ensure that applicable annual limits are not exceeded. Refer to [Fidelity.com/smallbusiness](Fidelity.com/smallbusiness) for applicable limits.  \n• Contributions will be deposited in each participant’s core account. Participants can place a trade in their account by going to [Fidelity.com](Fidelity.com) or calling Fidelity.  \n• Please keep a copy of your completed contribution remittance form for your records.  \n1. Employer Information  \n\n|  | Employer Name (i.e. , Company Name) |  | Employer Tax ID Number |\n| --- | --- | --- | --- |\n|  | \u003Cbr>Plan Administrator |  |  |\n|  | \u003Cbr>Primary Phone |  |  |\n| 2. Contribution Information All deposits may be subject to a four business day clearing period. |  |  |  |\n\n| Employee Name | Fidelity Account Number | Employee 401(k)/ Roth 401(k) Contribution |  | Employer Profit Sharing Contribution (KCT)* |  | Total Contribution |\n| --- | --- | --- | --- | --- | --- | --- |\n|  |  | Current Year (CYP) | Prior Year (PYP) |  |  |  |\n|  |  | $ | $ | $ |  | $ 0.00 |\n|  |  | $ | $ | $ |  | $ 0.00 |\n|  |  | $ | $ | $ |  | $ 0.00 |\n| *To the extent applicable, include any safe harbor nonelective contributions. |  |  |  |  | Total $ 0.00 |  |\n\n3. Authorization  \nBy signing below, you:  \n• Understand that you are required to comply with applicable contribution limits and deadlines.  \n• Hereby authorize Fidelity Brokerage Services LLC (“Fidelity”) to deposit the dollar amounts to the designated account(s), as instructed above.  \n• Understand it is your responsibility to allocate contributions to the appropriate employee and contribution source correctly. Failure to  \nclearly designate a contribution type may result in the entire check being returned to you for further instructions, for which Fidelity will not be responsible for delay(s) in contributions.  \n• Agree to fully indemnify and hold Fidelity and its affiliates harmless for any liability that may arise from Fidelity acting upon your instructions.  \n\n| PRINT PLAN ADMINISTRATOR OR EMPLOYER NAME |  |\n| --- | --- |\n|  |  |\n| PLAN ADMINISTRATOR OR EMPLOYER SIGNATURE\u003Cbr>X\u003Cbr>SIGN | DATE MM/DD/YYYY |\n\nOn this form, “Fidelity” means Fidelity Brokerage Services LLC and its affiliates. Brokerage services are provided by Fidelity Brokerage Services LLC, Member NYSE, SIPC. 390265.7.0 (11/25)  \n1.785683.108  \nPage 1  \nof 1  \n032610201","cbCaifKQHrR0T0PU","https://ap.wps.com/l/cbCaifKQHrR0T0PU","pdf",1156375,"English","# Employer Information\n# Contribution Information\n# Authorization","[{\"question\":\"What is the purpose of this form?\",\"answer\":\"Use the form to submit contribution deposits to a Fidelity Self-Employed 401(k) Plan or Roth Self-Employed 401(k) Plan account(s).\"},{\"question\":\"How should contributions be allocated on the form?\",\"answer\":\"Indicate the allocation for each plan participant to the applicable contribution sources: Employee 401(k), Roth 401(k), and/or Employer Profit Sharing Contributions. You must separately account for the two different contribution types to avoid exceeding annual limits.\"},{\"question\":\"What happens if a contribution type is not clearly designated?\",\"answer\":\"Failure to clearly designate a contribution type may result in the entire check being returned for further instructions, and Fidelity will not be responsible for delays in contributions.\"}]","Self-Employed 401(k) Contribution Remittance Form - Contribution Remittance | PDF",1789805914]