Questions? Call 1-800-544-5373, option 3.

1.801798.102 Page 1 of 2 007420101

Fidelity Investment-Only Retirement Account Contribution FormUse this form to allocate contributions to your Fidelity Investment-Only Retirement Account(s) (also known as the Fidelity Non-Prototype Retirement Account). Type on screen or fill in using CAPITAL letters and black ink. If you need more room for information, use a copy of the relevant page.

Helpful to Know • An Investment-Only Retirement Account provides an

investment vehicle for qualified retirement plan assets. Fidelity does not provide trustee, recordkeeping, tax-withholding, or tax-reporting services for this type of account.

• Do NOT use this form to purchase individual securities other than mutual funds. Visit Fidelity.com or contact a Fidelity representative at 1-800-544-6666 to place a trade after this deposit has posted to your account(s).

• All deposits must meet mutual fund eligibility and minimum investment requirements as described in the applicable fund prospectus or fact kit. You cannot invest in accounts that are restricted. If purchasing a new fund, you must have read the prospectus and agree to its terms.

• All deposits may be subject to a four business day clearing period.

• Only checks payable to Fidelity Investments or to the Fidelity fund name will be accepted. Fidelity does not accept third-party checks.

• You will want to keep a copy of all completed forms for your records.

Make checks payable as follows:• Brokerage Accounts — Fidelity Investments• Mutual Fund Accounts — Fidelity Fund Name (e.g., Fidelity®

Government Cash Reserves)

1. Plan and Trust InformationEmployer Name (i.e., Company Name) Plan Tax Identification Number

Trustee Name

Daytime Phone Extension

2. Deposit Information Indicate below how to allocate contributions for each Plan Participant account.

1Plan Participant Name Plan Participant Account Number

Fidelity Fund Name or Symbol Amount

$ .

2Plan Participant Name Plan Participant Account Number

Fidelity Fund Name or Symbol Amount

$ .

3Plan Participant Name Plan Participant Account Number

Fidelity Fund Name or Symbol Amount

$ .

Brokerage accounts: Investments will be

placed in the core posi-tion unless you specify

mutual fund position(s). Do NOT list individual

securities other than mutual funds on this

form. See instructions in the Helpful to Know

section above if you want to purchase

individual securities.

Mutual Fund Only accounts: Investments

will be placed in the mutual fund position(s)

as specified. Only Fidelity mutual funds

may be listed.

Form continues on next page.

1.801798.102 Page 2 of 2 007420102

On this form, “Fidelity” means Fidelity Brokerage Services LLC and its affiliates. Brokerage services are provided by Fidelity Brokerage Services LLC, Member NYSE, SIPC. 375395.3.0 (11/15)

Make Checks Payable to: Fidelity Investments or to the Fidelity fund name

Questions? Call 1-800-544-5373, option 3.

Use postage-paid envelope OR mail to:

Regular mail Fidelity Investments P.O. Box 770001 Cincinnati, OH 45277-0048

Overnight mail Fidelity Investments 100 Crosby Parkway, KC1H Covington, KY 41015

4Plan Participant Name Plan Participant Account Number

Fidelity Fund Name or Symbol Amount

$ .

5Plan Participant Name Plan Participant Account Number

Fidelity Fund Name or Symbol Amount

$ .

6Plan Participant Name Plan Participant Account Number

Fidelity Fund Name or Symbol Amount

$ .

7Plan Participant Name Plan Participant Account Number

Fidelity Fund Name or Symbol Amount

$ .

8Plan Participant Name Plan Participant Account Number

Fidelity Fund Name or Symbol Amount

$ .

9Plan Participant Name Plan Participant Account Number

Fidelity Fund Name or Symbol Amount

$ .

10Plan Participant Name Plan Participant Account Number

Fidelity Fund Name or Symbol Amount

$ .