1.814877.107 012340201Page 1 of 3
Questions? Call 800-544-5373.
Defined Contribution Retirement Plan
Use this form to provide updated information about your company’s current Fidelity Self-Employed 401(k), Profit Sharing, and/or
Money Purchase Plan(s). Do NOT use this form to establish a new Defined Contribution Retirement Plan with Fidelity. Type on screen
or fill in using CAPITAL letters and black ink. If you need more room for participant information, make a copy of the relevant page.
Helpful to Know
• This form should be completed by the Employer.
• Providing your Employer (Tax) Identification Number
(EIN) enables Fidelity to report all your plan assets
(including any employees’ assets) on one Annual
Valuation Statement, which Fidelity will mail to help you
prepare your Form 5500 reporting.
• Your EIN is not the same as your Social Security
number. To obtain an EIN for your Plan, you can file IRS
Form SS-4 or call the IRS directly at 800-829-4933.
• If you are appointing a new Plan Administrator, Fidelity
will designate this individual as the main contact for the
Plan. Do not list a company as a Plan Administrator. Be
sure to provide the requested information in Section 2
to ensure that any future mailings regarding the Plan
• The Plan Administrator is a “named fiduciary” for
purposes of ERISA Section 402(a)(1) and has the powers
and responsibilities with respect to the management
and operation of your company’s Plan.
• If you have not already done so, it is recommended that
you appoint a second individual as a Successor Plan
Administrator to act on behalf of the Plan in the event
that the named Plan Administrator dies, resigns, or is
unwilling to act on behalf of the Plan.
• To learn more about the duties of the Plan
Administrator or Successor Plan Administrator, please
refer to Section 11.2(b) of the Plan Document.
• You should also update the appropriate Adoption
Agreement(s) with this information and retain copies
of all completed documents.
1. Plan Information
Employer (Tax) Identification Number Plan Name
2. Plan Administrator Information
To appoint or update your Plan Administrator and/or Successor Plan Administrator, provide the requested information below.
Plan Administrator The Plan Administrator serves as the main contact for the Plan.
Plan Administrator Name Do not list a company.
City State ZIP Code
Daytime Phone Extension
Note: Fidelity will
use this information
to provide any future
to the Defined
Retirement Plan, as
well as the Annual
Plan Administrator Information continues on next page.