Fidelity Investments 403(b) Benefi ciary Designation ...

Fidelity Investments

403(b) Beneficiary Designation

1. FGiEdNeEliRtyALInINveSTsRtmUCeTnIOtsNS

403(b) This form is for plans that DO NOT require spousal consent for a beneficiary designation. Beneficiary Designation Please complleetteetthhiissffoorrmmaannddsisgignnititoninthSecbtiaocnk.3Inofththeefuftourrme,.yIonuthmeafyurtuevroe,kyeotuhembaeynerfievcioakrye dtheesigbnenateiofinciarnydddeessiiggnnaattieoandainffderdenestignate

abednifeffiecreianrtybbeynseufibcmiaritytinbgy asunbemwitBteingefiacniaerwy DBesnigenfiactiiaorny FDoersmigntoatFioidneFlitoyr.m to Fidelity or by logging into Profile.

PMleaaisleinrgetuinrsnttrhuicstcioomnsp:leted form: Return th1is.foGrmEiNn tEhRe eAnLcloIsNedSpToRstaUgeC-pTaIiOd eNnvSelope or to This form is for plans thaFtiDdeOlitDNyOiIgnTviteraestqllmuyierunetsssip,noPg.uOst.ahlBecooxNn7see7nt0Bt0f0eo2nr,eaCfibintecsnin?enfiMactiiao,rOby iHdlee4s5Aig2np7a7pt-i0o0n9. 0

Please complete this form and siDgnoIwfitnyoolnouatdwheitshbheatcNoke.steIBnnedtnheyefoiftuusr?tufaroper,pmytovhuiraomuoavgyehrrntehvigeohkAtepstpehrleevibSceteno,erpefilceoiarasrGeyosdeoengsdlieginPtalttaoiyo.n and designate a different beneficiary by submitFtiindgealitnyewInBveensetfimciearnytsD,eMsiganialTztaioopnn:eFAoKcrtmCio1ntEos,F>1idS0ee0lintyCd. raoDsboycuPmaernkwt ay, Covington, KY 41015 QMuaeilisntgioninss?trCuaclltiFoindesl:ity InvestmentRseattu1rn-8t0h0is-O3fo4rr3um-s0ei8no6nt0he,eMoefnotnhcldeosaseyedatlhtperoornsutagathgeeFm-preiadtihadyo,ednfsrv:oemlop8:e0o0rAt.oM. to midnight ET, or visit us at fide atwork. FideRli etyguInlavre Mstmailen ts, P.O. Box 77000 2, CinOc ivnenrantiig, OhtHM4a5il277-0090

You are not lim it eFdidteo littwy oInpv CFPreIfiOisimdynteo2mcBalui iorn.teyxywnnD aaI7itnstn7Esihv,,0dSeOt0MsoIt0tHG wmas2e i4oeNlnzn5doct2Asony7Ton7eu-It0NKirn0CfgoG91re0mEnY,tvO1iba0eUo0nvReCerfirnBco iigsEahbrNtiyes1CFEePs0ir.o adFv0vTreiIicoklCnCiewtgar,yIo stpaAosIsliynbn egR,vy,anCes KYPesaoYta(dmsrvIde4kEieni1nwtnSdi0goat1)siytnt,5oatKlnoCb, e1KnEYefi4c1ia0ri1es5, or to make a more

cQoumepslteixobnesn?eCficailal rFyiddeelsitigynIantvioesnt,mpelenatseaat t1ta-8ch0,0s-3ig4n3,-a0n8d60d,atoer afosrepthaerahteapriencgeiomfppaaipreedr.dial 717 11, 7M1 onday through Friday, from 8:00 A.M. tWo hmeidnndigehstiEgTn,aotirnvgispitruims aatrywawnwd.fciodneltiitnyg.ceonmt/abtewnoerfikc. iaries, please use whole percentages and be sure that the percentages

for each group of beneficiaries total 120.0%D.EYoSuIrGpNrimAaTryINbeGnefiYciOarUy cRanBnoEt NbeEyFouICr cIoAnRtinYg(eInEt Sbe)neficiary. If you designate a trust as a

beneficiary, please include the date the trust was created, and the trustee's name. UYonulesasroethneortwliisme sitpeedcifitoedtbwyoyopurrimplaarny, iafnmdotrewtohacnoonnteinpgeersnotnbisenneamficeidaraineds.nToopaesrsciegnntaagdedsitairoenianldbiecnateefidc,iapraieysm, eonrttowmillabkee ma amdoere icnomeqpuleaxl sbheanreesfictoiaryyoudrespirginmaatiroynb, epnleeafisceiaartyta(icehs,) swighno, saunrdvidvaetseyaosue.pIafraatpeeprcieecnetaogfepiaspinerd.icated and a primary beneficiary(ies) does nWoht esunrvdiveesiygonua, ttihnegpperrciemnatargye aonf dthactobnetninefigceianrty'bs edneseigfincaiaterdiessh,aprelesahsalel buesediwvidheodleampoenrcgetnhetasguervsivainndg bperimsuarreythbaetntehfiecipaeryrc(eienst)ages ifnorperaocphorgtrioounptoofthbenpeefirceianrtiaegsetostealel c1t0ed0%fo.rYtohuermp.rimary beneficiary cannot be your contingent beneficiary. If you designate a trust as a

beneficiary, please include the date the trust was creat3ed. ,AanUdTthHe OtruRstIeZe'As nTaImOeN.

Unless otherwise specified by your plan, if more than one person is named and no percentages are indicated, payment will be made Pinleeaqsuealpshroarveisdteo youurrpsriigmnaartyubreen.eficiary(ies) who survives you. If a percentage is indicated and a primary beneficiary(ies) does not survive you, the percentage of that beneficiary's designated share shall be divided among the surviving primary beneficiary(ies) in proportion to the percentage selected for them.

3. AUTHORIZATION

Please provide your signature.

Fidelity Investments Institutional Operations Company,LInLCc..

Fidelity Investme5ntVs FInITstSituRtiPonEa0l 0O1pLerations Company, Inc.

Page 1

Fidelity Investments

403(b) Beneficiary Designation

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:

Address Line 2:

City:

State:

Zip:

Daytime Phone: Name of Employer:

Evening Phone:

Plan Number (if known):

I am:

Single OR

Married Name of Site/Division:

2. DESIGNATING YOUR BENEFICIARY(IES)

Please check here if you have more than two primary or contingent beneficiaries.

Primary Beneficiary(ies)

I hereby designate the person(s) named below as primary beneficiary(ies) to receive payment of the value of my account(s) under the plan upon my death.

1. Individual or Trust Name:

Percentage:

%

Social Security #: Date of Birth or Trust Date:

Trust ID #:

Relationship to Applicant:

Spouse OR

Trust OR

Other

2. Individual or Trust Name:

Percentage:

%

Social Security #: Date of Birth or Trust Date:

Trust ID #:

Relationship to Applicant:

Spouse OR

Trust OR

Other

Total = 100%

Page 2

2. DESIGNATING YOUR BENEFICIARY(IES) (CONTINUED)

Contingent Beneficiary(ies)

If there is no primary beneficiary living at the time of my death, I hereby specify that the value of my account is to be distributed to my contingent beneficiary(ies) listed below. Please note: Your primary beneficiary cannot be your contingent beneficiary.

1. Individual or Trust Name:

Percentage:

%

Social Security #: Date of Birth or Trust Date:

Trust ID #:

Relationship to Applicant:

Spouse OR

Trust OR

Other

2. Individual or Trust Name:

Percentage:

%

Social Security #: Date of Birth or Trust Date:

Trust ID #:

Relationship to Applicant:

Spouse OR

Trust OR

Other

Total = 100%

Payment to contingent beneficiary(ies) will be made according to the rules of succession described in the instructions.

3. SIGNATURE AND AUTHORIZATION

Individual Authorization: By executing this form

? I certify under penalties of perjury that my Social Security number in Section 1 on this form is correct. ? I am aware that the beneficiary information included in this form becomes effective when delivered to Fidelity and will remain in

effect until I deliver another completed and signed Beneficiary Designation Form to Fidelity with a later date. ? I am aware that the beneficiary information provided herein shall apply to all my Fidelity Accounts under the plan listed in Section 1

for which Fidelity Management Trust Company (FMTC) (or its affiliates and/or any successor appointed pursuant to the terms of such Accounts or trust agreement in effect between FMTC and my Employer, as applicable) acts as trustee or custodian, and shall replace all previous designation(s) I have made on any of my Accounts.

X Your Signature:

Date:

5VFITSRPE002M

Page 3

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FFiiddeelliittyyIInnvveessttmmeennttssIInnssttiittuuttiioonnaallOOppeerraattiioonnssCCoommppaannyy,LILnCc. 11.883388448866.110001

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