Fill - Free fillable Completing the Self-Employed 401(k) Adoption Agreement No. 001 (Fidelity Investments) PDF form

Completing the Self-Employed 401(k)

Adoption Agreement No. 001

For help with completing this adoption agreement, you should also refer to your last completed adoption

agreement in your records.

1.866722.106 032970201Page 1 of 6

Questions? Go to Fidelity.com/se401k or call 800-544-5373.

The Defined Contribution Retirement Plan —

Profit Sharing/401(k) Plan Adoption Agreement No. 001

A pre-approved plan for use with the Defined Contribution Retirement Plan, Basic Plan Document No. 04

1. Plan Information

A. Name of Plan:

This is the

(the “Plan”)

Plan Number

The Plan consists of the Basic Plan Document, this Adoption Agreement as completed, and the separate

Trust Agreement.

B. Name of Plan Administrator (if not the Employer):

Name

Address

City State ZIP Code

Telephone Number Email Address

The Plan Administrator serves as the main contact for the Plan and the designated agent for service of legal process

for the Plan.

Name of Successor Plan Administrator:

Name

Address

City State ZIP Code

Telephone Number Email Address

[Note: The failure to name a successor Plan Administrator may result in the delay of Plan distributions, if the Plan

Administrator is unable to fulfill its duties.]

Plan Information continues on next page.

C. Type of Plan:

1. Profit Sharing only — Elective Contributions (401(k) contributions) are not permitted. The Employer may

make Nonelective Employer Contributions in the manner elected in this Adoption Agreement.

2. Safe Harbor 401(k) Plan — Elective Contributions (401(k) contributions) are permitted and the Employer

will make Safe Harbor Nonelective Employer Contributions to the Plan on behalf of Eligible Participants

equal to 3% of their “Compensation” for the Plan Year. The Employer may make Nonelective Employer

Contributions in the manner elected in this Adoption Agreement.

3. Non-Safe Harbor 401(k) Plan — Elective Contributions (401(k) contributions) are permitted. The Employer

will not make Safe Harbor Nonelective Employer Contributions to the Plan. The Employer may make

Nonelective Employer Contributions in the manner elected in this Adoption Agreement.

D. Plan Year and Limitation Year:

1. Calendar Year 2. Fiscal Year ending

MM DD

[Note: If left blank, the Plan Year and Limitation Year will be the calendar year.]

E. Plan Status and Effective Date:

1. New Plan Effective Date:

Date MM DD YYYY

[Note: Cannot be earlier than the

first day of the current Plan Year.]

2. Amendment Effective Date:

Date MM DD YYYY

[Note: Cannot be earlier than the

first day of the current Plan Year.]

This is:

a. an amendment and restatement of a Basic Plan Document No. 04 Adoption Agreement previously

executed by the Employer. With the execution of this restatement, the Trust Agreement formerly

within Basic Plan Document No. 04 is hereby removed to become a separate, independent Trust

Agreement without altering the substance thereof.

b. an amendment and restatement from another plan document to a Basic Plan Document No. 04

Adoption Agreement.

The original effective date of the Plan MM DD YYYY

Complete if adding Elective Contributions (401(k) contributions) to your Plan for the first time:

Effective date of Elective Contributions:

Date MM DD YYYY

[Note: Cannot be earlier than the day this

amended Adoption Agreement is signed.]

2. Employer

Name of Employer

Address

City State ZIP Code

Telephone Number Employer’s Tax Identification Number

Check one.



Check one.

Page 2 of 61.866722.106 032970202

Employer continues on next page.

1. Plan Information, continued



Enter the name of your plan and the plan

number.

The 3-digit plan number is assigned by you

and should correspond to the number you report

on Form 5500, if applicable. (For example, your

ﬁrst plan is 001, the next plan you adopted is 002,

and so on.)

Complete the Employer information. Do not

provide a Social Security number for your

Employer Tax Identiﬁcation Number.

Provide the name, address, and telephone number

of the Plan Administrator. Each plan should have

only one individual (not a company) listed as a Plan

Administrator.

You should also consider naming a

second individual as a Successor Plan

Administrator to act on behalf of the plan

in the event the named Plan Administrator dies,

resigns, or is unwilling or otherwise unable to act

on behalf of the plan, as deﬁned in Article 2.33 of

the Plan Document.

Check the box for “Amendment Effective Date”

and complete the date, generally the ﬁrst day

of the plan year in which you sign the restating

adoption agreement.

This is an amendment and restatement of a Basic Plan

Document No. 04 Adoption Agreement previously

executed by the Employer.

You should also indicate the original effective date

of your plan in the space provided.

Page 3 of 6

B. The term “Employer” includes the following Affiliated Employers covered by the Plan:

[Note: All Affiliated Employers are required to be covered under the terms of the Plan.]

3. Coverage

A. The eligibility requirements for participation in the Plan will be:

1. Eligibility Service Requirement:

a. No eligibility service requirement.

b. Six months of employment. (If this option is selected, an Employee will not be required to complete

any specified number of Hours of Service in the six-month period.)

c. One Year of Service.

d. Two Years of Service. (This option may only be selected if Section 1.C.1, Profit Sharing only, is selected

above. This option may not be selected if the Plan provides for Elective Contributions (401(k) contributions).)

2. Age Requirement:

a. No minimum age requirement.

Years (Cannot be more than 21.)

B. An Employee who has satisfied the eligibility requirements for participation in Section 3.A above will become a

Participant on the following date, provided he is an Employee:

1. On the first day of the calendar month in which such requirements are satisfied.

2. On the first day of the Plan Year and the first day of the seventh month of the Plan Year (whichever is

earlier) coinciding with or immediately following the date on which such requirements are satisfied.

C. The requirements listed above are:

1. Applicable to all Employees.

2. Applicable to all Employees, except those Employees employed on the Effective Date. Such Employees

will participate immediately. All other Employees will need to satisfy the requirements listed above.

4. Compensation

Contributions for the Plan Year in which an Employee first becomes a Participant shall be determined based on the Employee’s “Compensation”:

A. For the entire Plan Year.

B. For the portion of the Plan Year in which the Employee is eligible to participate in the Plan.

[Note: “Compensation” is defined in Article 2.12 of the Basic Plan Document.]

Check one.

1.866722.106 032970203

Form continues on next page.

2. Employer, continued

Check one.

Page 4 of 61.866722.106 032970204

5. Discretionary Nonelective Employer Contributions

If A or B is elected below, the Employer may make discretionary Nonelective Employer Contributions on behalf of each Participant in

accordance with the provisions of this Section 5 and the Basic Plan Document.

A. Allocation of Nonelective Employer Contributions will not be integrated with Social Security. [See Article 4.10

of the Basic Plan Document.]

B. Allocation of Nonelective Employer Contributions will be integrated with Social Security. [See Article 4.11 of

the Basic Plan Document.]

If the Plan will be integrated with Social Security, fill in the blanks below:

1. The Integration Level means the Social Security Taxable Wage Base for the Plan Year, unless the Employer

elects a lesser amount in (a) or (b) below:

(may not exceed the Taxable Wage Base).

of the Taxable Wage Base in effect on the first day of each Plan Year (may not exceed 100%).

2. The Excess Contribution Percentage (which may not exceed the Profit Sharing Maximum Disparity Rate

described below) will be:

3. The Profit Sharing Maximum Disparity Rate shall be:

a. Unless an Integration Level other than the Social Security Taxable Wage Base is specified in

Section 5.B.1 above, 5.7%.

b. If a different Integration Level is specified in Section 5.B.1 above, the applicable percentage

determined in accordance with the table below:

If the Integration Level is more than: But not more than: The applicable percentage is:

$0 X* 5.7%

X* 80% of TWB 4.3%

80% of TWB Y** 5.4%

*X = the greater of $10,000 or 20% of the TWB.

**Y = any amount more than 80% of the TWB but less than 100% of the TWB.

6. Normal Retirement Age

A. Unless otherwise elected below, Normal Retirement Age means age 59½.

1. The Employer adopted a Normal Retirement Age of 55 before January 1, 2009. [Note: This election is only

available if the Employer previously adopted age 55 as the Plan’s Normal Retirement Age. If the Plan’s

prior Normal Retirement Age was age 55, the Employer’s ability to increase the Normal Retirement Age

to age 59½ is limited by Article 10.3 of the Basic Plan Document and applicable anti-cutback provisions of

ERISA and the Code.]

Check one.

Form continues on next page.

If you have ownership interest in more than one

business, you should consult your tax advisor or

refer to Article 2.3 of the Plan Document to see

if you should ﬁll out this section.

IRS guidelines require that you provide the names of any

Afﬁliated Employers whose employees are covered by

this plan.

Skip this section unless the plan adopted a

Normal Retirement Age of 55 before January 1,

2009. Unless you previously adopted age 55

as the plan’s Normal Retirement Age, the Normal

Retirement Age is age 59½.

Indicate the eligibility and coverage

requirements in effect as of the amendment

effective date you provided in Section 1.

Social Security Integration (permitted disparity) is

designed for multi-participant plans and is not generally

appropriate for a Self-Employed 401(k) Retirement

Plan, self-employed individuals, or owner-only

businesses.

You can check Box A to indicate that

Contributions will not be integrated with

Social Security, or consult a tax advisor ﬁrst to

determine what is appropriate for your Plan.

Page 5 of 61.866722.106 032970205

7. Multiple Qualified Plans

Select A or B below only if the Employer maintains other qualified plans and uses a method of satisfying the 415 limits or the top-heavy

minimum contribution requirements different from the method provided under the Plan.

A. Other Order for Limiting Annual Additions: If the Employer maintains other defined contribution plans,

annual additions to a Participant’s Account shall be limited as provided in Article 12.3 of the Basic Plan

Document to meet the requirements of Code Section 415, unless the Employer elects this Option and

completes the 415 Correction Addendum describing the order in which annual additions shall be limited

among the plans.

B. Other Method to Satisfy Top-Heavy Minimum Contribution Requirement: If the Employer maintains

other qualified plans that are aggregated with the Plan for top-heavy purposes, the minimum contribution

requirement will be met as provided in Article 13.2 of the Basic Plan Document, unless the Employer elects

this Option and completes the 416 Contributions Addendum to the Adoption Agreement describing the way

in which the minimum contribution requirements will be satisfied in the event the Plan is or is treated as a

“top-heavy plan.”

8. Reliance on Opinion Letter

This is a “standardized” pre-approved plan. You may rely on the opinion letter issued by the Internal Revenue Service as evidence that

your Plan is qualified under Section 401 of the Internal Revenue Code except to the extent provided in Section 7.01 of Revenue Procedure

2017-41. You may not rely on the opinion letter in certain other circumstances or with respect to certain qualification requirements, which

are specified in Section 7.03 of Revenue Procedure 2017-41.

If you have ever maintained or later adopt any plan (including a welfare benefit fund as defined in Section 419(e) of the Internal Revenue

Code, which provides post-retirement medical benefits allocated to separate accounts for key employees, as defined in Section 419A(d)(3)

of the Internal Revenue Code or an individual medical account, as defined in Section 415(1)(2) of the Code) in addition to the Plan, you will

not be able to rely on the opinion letter issued by the Internal Revenue Service for the Pre-Approved Plan with respect to the requirements

of Sections 415 and 416 of the Internal Revenue Code. You will not be considered to have maintained another plan merely because you

maintained another defined contribution plan, provided that (i) the other defined contribution plan terminated before the effective date of

the Plan and (ii) no annual additions were credited to the account of any participant under such other plan within a limitation year of the

Plan. If you adopt or maintain multiple plans and you wish to obtain reliance with respect to the requirements of Sections 415 and 416 of

the Internal Revenue Code, you must apply to Employee Plans Determinations of the Internal Revenue Service for a determination letter

with respect to your Plan.

Failure to properly complete the Adoption Agreement and failure to operate the Plan in accordance with the terms of the Plan document

may result in disqualification of the Plan.

9. Provider Information

A. Name of Provider:

FMR LLC

B. Address of Provider:

245 Summer Street

Boston, Massachusetts 02210

800-544-5373

Questions regarding this pre-approved plan document may be directed to the Provider.

Form continues on next page.

Page 6 of 61.866722.106 032970206

10. Execution Page

The Employer appoints Fidelity Management Trust Company as Trustee and agrees to the fees set forth in the Retirement Plan Account

Application, as amended from time to time. The Employer hereby directs the Trustee to invest any funds of the Plan that are transmitted

without complete investment instructions in Fidelity Government Cash Reserves.

The Adoption Agreement may be used only in conjunction with Defined Contribution Retirement Plan, Basic Plan Document No. 04. Failure

to fill out this Adoption Agreement properly may result in the disqualification of the Plan. The Provider shall inform the adopting Employer

of any amendments made to the Plan or of the discontinuance or abandonment of the Pre-Approved Plan.

IN WITNESS WHEREOF, the Employer has caused this Adoption Agreement to be executed

This day of

EMPLOYER (NAME OF BUSINESS)

PRINT NAME OF PERSON SIGNING BELOW

SIGNATURE OF EMPLOYER

SIGN

DATE MM/DD/YYYY

DATE

On this form, “Fidelity” means Fidelity Brokerage Services LLC and its affiliates. Brokerage services are

provided by Fidelity Brokerage Services LLC, Member NYSE, SIPC. 493049.7.0 (03/21)

Did you sign the form and include any necessary documents?

Send the ENTIRE form and any account application(s) to

Fidelity Investments.

Questions? Go to Fidelity.com/se401k or call 800-544-5373.

Regular mail

Fidelity Investments

PO Box 770001

Cincinnati, OH 45277-0036

Overnight mail

Fidelity Investments

100 Crosby Parkway KC1K

Covington, KY 41015

You must complete and sign Section 10 before the

amendment is effective for your plan. Keep the

signed Adoption Agreement along with the amended

Basic Plan Document No. 04 in your permanent business

records in the event you need to present a copy to the

Department of Labor (DOL) or Internal Revenue Service (IRS).

Fidelity Brokerage Services LLC, Member NYSE, SIPC

728497.2.0 900 Salem Street, Smithﬁeld, RI 02917 1.9865995.101

Skip this section if you are only operating one

qualiﬁed plan.

1.866722.106 032970201Page 1 of 6

Questions? Go to Fidelity.com/se401k or call 800-544-5373.

The Defined Contribution Retirement Plan —

Profit Sharing/401(k) Plan Adoption Agreement No. 001

A pre-approved plan for use with the Defined Contribution Retirement Plan, Basic Plan Document No. 04

1. Plan Information

A. Name of Plan:

This is the

(the “Plan”)

Plan Number

The Plan consists of the Basic Plan Document, this Adoption Agreement as completed, and the separate

Trust Agreement.

B. Name of Plan Administrator (if not the Employer):

Name

Address

City State ZIP Code

Telephone Number Email Address

The Plan Administrator serves as the main contact for the Plan and the designated agent for service of legal process

for the Plan.

Name of Successor Plan Administrator:

Name

Address

City State ZIP Code

Telephone Number Email Address

[Note: The failure to name a successor Plan Administrator may result in the delay of Plan distributions, if the Plan

Administrator is unable to fulfill its duties.]

Plan Information continues on next page.

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