Fidelity Investments Workplace Savings Plan Contribution Form 401(A/k) Or 403(B) Plan printable pdf download

Fidelity Investments Workplace Savings Plan Contribution Form 401(A/k) Or 403(B) Plan

Fidelity Investments

Workplace Savings Plan Contribution Form

401(a/k) or 403(b) Plan

Instructions: Use this Workplace Savings form if you wish your employer to deduct an amount of money from your paycheck to be

contributed to your employer’ s plan. If you do not have an account with Fidelity for the Employer named below, you must

also complete a Fidelity Investments Account Application. You may request these forms from your Beneﬁ ts Ofﬁ ce or by calling

Fidelity at 1-800-343-0860. Unless otherwise instructed, please complete this form and return it to your Human Resources department or

Beneﬁ ts ofﬁ ce. Please retain a copy of this form for your records.

DO NOT RETURN THIS FORM TO FIDELITY INVESTMENTS.

Questions? Call Fidelity at 1-800-343-0860, Monday through Friday, 8:00

. to midnight ET.

1. PARTICIPANT INFORMATION

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

Social Security #:

Date of Birth:

First Name:

Last Name:

Street Address:

Address Line 2:

City:

State:

Zip:

Daytime Phone:

Evening Phone:

Is this a new Workplace Savings Plan Contribution Agreement:

Yes

2. EMPLOYER INFORMATION

Name of Current Employer/Site/Division:

Address Line 2:

City:

State:

Zip:

3. APPLICABLE ACCOUNT

This authorization shall apply to the account selected below. (choose one)

401(k)

401(a)

403(b)

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Fidelity Investments Workplace Savings Plan Contribution Form 401(A/k) Or 403(B) Plan