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Contribution Remittance Form

This document is a contribution remittance form for a Fidelity Self-Employed 401(k) plan. It provides instructions for employers to submit contribution deposits to participant accounts, including making checks payable to Fidelity Investments and mailing addresses. The form requires the employer name and tax ID, participant names and account numbers, and allocation of contributions to employee 401(k) or employer profit sharing sources. The employer authorizes Fidelity to deposit the amounts and indemnifies Fidelity from liability.

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Asfand Yar Bajwa
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158 views1 page

Contribution Remittance Form

This document is a contribution remittance form for a Fidelity Self-Employed 401(k) plan. It provides instructions for employers to submit contribution deposits to participant accounts, including making checks payable to Fidelity Investments and mailing addresses. The form requires the employer name and tax ID, participant names and account numbers, and allocation of contributions to employee 401(k) or employer profit sharing sources. The employer authorizes Fidelity to deposit the amounts and indemnifies Fidelity from liability.

Uploaded by

Asfand Yar Bajwa
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Questions? Go to Fidelity.com/smallbusiness or call 800-343-3548.

Self-Employed 401(k) — Contribution Remittance Form


Use this form to submit contribution deposits to your Fidelity 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:
• Regular mail: Fidelity Investments, P.O. Box 770001, Cincinnati, OH 45277-0003
• Overnight mail: Fidelity Investments, 100 Crosby Parkway, KC1H, Covington, KY 41015

Helpful to Know
•B  e sure to indicate below how to allocate contributions for each limits are not exceeded. Refer to Fidelity.com/smallbusiness for
plan participant to the applicable contribution sources: Employee applicable limits.
401(k) and/or Employer Profit Sharing Contributions. • Contributions will be deposited in each participant’s core
• If we are unable to allocate contributions to the sources account. Participants can place a trade in their account by going
indicated, we will deposit them as Employer Profit Sharing to Fidelity.com or by calling Fidelity.
Contributions, and will then contact you on how to resolve them. • Please keep a copy of your completed contribution remittance
• Note: It is your responsibility to separately account for each of the form for your records.
two different contribution types to ensure that applicable annual

1. Employer Information
Employer Name (i.e., Company Name) Employer Tax ID Number

Plan Administrator

Daytime Phone Extension

2. Contribution Information All deposits may be subject to a four-business-day clearing period.

Employee Name Fidelity Account Number Employee 401(k) Contribution Employer Profit Sharing Total Contribution
Current Year (CYP) Prior Year (PYP) Contribution (CCR)*
$ $ $ $ 0.00

$ $ $ $ 0.00

$ $ $ $ 0.00

*To the extent applicable, include any safe harbor nonelective contributions. Total $ 0.00

3. Authorization
By signing below, you:
• Understand that you are required to •U
 nderstand that it is your responsibility to • Agree to fully indemnify and hold Fidelity
comply with applicable contribution limits allocate contributions to the appropriate and its affiliates harmless for any liability
and deadlines. employee and contribution source correctly. that may arise from Fidelity acting upon
• Hereby authorize Fidelity Brokerage Failure to clearly designate a contribution your instructions.
Services LLC (“Fidelity”) to deposit type may result in the entire check being
the dollar amounts to the designated returned to you for further instructions, for
account(s), as instructed above. which Fidelity will not be responsible for
delay(s) in contributions.

PRINT PLAN ADMINISTRATOR OR EMPLOYER NAME

PLAN ADMINISTRATOR OR EMPLOYER SIGNATURE DATE MM/DD/YYYY

X X
SIGN

On this form, “Fidelity” means Fidelity Brokerage Services LLC and its affiliates. Brokerage services are
provided by Fidelity Brokerage Services LLC, Member NYSE, SIPC. 390265.5.0 (06/17)

1.785683.106 Page 1 of 1 032610101

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