Sample Contribution Remittance Form



Contribution Remittance Form

|The Rabbis and Cantors |[pic] |Fidelity Investments |

|Retirement Plan | |P.O. Box 770002 |

|Client Number – 19000 | |Cincinnati, Ohio 45277-0089 |

|PARTICIPANT INFORMATION |EMPLOYEE | EMPLOYER |

| |PRE-TAX |CONTRIBUTION |

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|SOCIAL SECURITY |LAST NAME |FIRST NAME |AMOUNT |AMOUNT |

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| | |Source Total | | |

|Please: | |

|Make checks payable to FMTC. |Enter Total |

|Include your client number (19000) on your check. |Contribution Amount: |

|For information regarding your Program, please call your Client Services Team at: | |

|1-800-868-1023 Monday - Friday 8 a.m. - 7 p.m. Eastern Time. | |

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|Remittance Prepared by: | | |$ ____________________ |

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|Daytime Phone: | | | | |Check |

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|Contribution Year: |20 | | | | | | |

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(Investments will be recorded as current year contributions unless otherwise indicated.)

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