Fidelity Advisor SIMPLE IRA Plan Salary Reduction Agreement
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Fidelity Advisor SIMPLE IRA Plan
Salary Reduction Agreement
Use this form to direct your Employer to defer part of your compensation to your company's SIMPLE IRA Plan or to change your existing Salary Reduction Agreement. See your SIMPLE IRA Plan Summary Description to determine when changes may be made to an existing Salary Reduction Agreement.
DO NOT mail this form back to Fidelity. Complete and retain a copy of this form for your records and return this form to the place or individual designated by your Employer.
1. Employee Information
Name First, M.I., Last
SSN
Street Address
Apartment
City
State Zip/Postal Code
Name of Employer Company
2. Salary Reduction Election
Subject to the requirements of the SIMPLE IRA Plan of the above-named Employer, I authorize
Percentage
Amount
% of my salary, or $
.
to be withheld from my pay for each pay period and
contributed to my SIMPLE IRA as a salary reduction contribution.
I have read and understood the SIMPLE IRA Plan Summary Description and Appendix (if applicable) provided to me by my Employer.
3. Maximum Salary Reduction
If I will be under age 50 by the end of the relevant year, I understand that the total amount of my salary reduction contributions cannot exceed $14,000* for 2022.
If I will be age 50 or over by the end of the relevant year, I understand that the total amount of my salary reduction contributions cannot exceed $17,000* for 2022.
*These amounts may be adjusted to reflect any annual cost-of-living increases announced by the IRS.
4. Date Salary Reduction Begins
Fill in the date you want the salary reduction
contributions to begin; the date must be after the date you sign this
Agreement.
I understand that my salary reduction contributions will start as soon as permitted under the SIMPLE IRA Plan and as soon as administratively feasible or, if later,
Date MM DD YYYY
5. Duration of Election
I understand that this Salary Reduction Agreement replaces any earlier agreement and will remain in effect as long as I remain an Eligible Employee under the SIMPLE IRA Plan or until I provide my Employer with a request to end my salary reduction contributions or provide a new Salary Reduction Agreement as permitted under my Employer's SIMPLE IRA Plan.
Employee Signature
Date MM - DD - YYYY
SIGN
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Fidelity Advisor SIMPLE IRA Plan
Sample Notice to Eligible Employees
Dear Employee:
Our company offers a SIMPLE IRA Plan as a retirement benefit. Upon opening a SIMPLE IRA in your name, you are eligible to make salary reduction contributions and receive company contributions as described below. This Notice and the Summary Description (and Appendix, if applicable) provide you with information that you should consider before you decide whether to start, continue, or change your Salary Reduction Agreement.
Company Contribution One of the features of a SIMPLE IRA Plan is that the Plan is funded by both employee and company contributions. For the _______ calendar year the company has elected to contribute to your SIMPLE IRA (Employer must select either A, B, or C):
A.a matching contribution equal to your salary reduction contributions up to a limit of 3% of your compensation for
the year.
B.a matching contribution equal to your salary reduction contributions up to a limit of _____% (Employer must insert
a number from 1?3 and is subject to certain restrictions) of your compensation for the year.
C.a nonelective contribution equal to 2% of your compensation for the next year (eligible compensation limited to
$305,000 for 2022) if you are an employee who makes at least $______________ (Employer must insert an amount that is $5,000 or less) in compensation for the year.
How to Enroll If you decide to start or change your Salary Reduction Agreement, you must complete the Salary Reduction Agreement and return it to:
(Employer should designate a place or an individual.)
by
(Employer should insert a date that is no less than 60 days after notice is given.)
Sincerely,
SAMPLE
The trademarks and service marks appearing herein are the property of FMR LLC.
Fidelity Investments Institutional Operations Company LLC
955876.2.0
1.537484.126
0322
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