Defined Contribution Retirement Plan —
401(k) Salary Reduction Agreement
1.824975.115
On this form, “Fidelity” means Fidelity Brokerage Services LLC and its affiliates.
Brokerage services are provided by Fidelity Brokerage Services LLC, Member NYSE,
SIPC. 511261.13.0 (10/20)
Use this form to indicate the amount you wish to have withheld from your compensation and contributed as a salary deferral contribution
to your account in the Defined Contribution Retirement Plan, or to change or terminate your existing Salary Reduction Agreement.
All participants, including owners, must complete this Agreement. This form should be retained with your plan’s records and does not
need to be returned to Fidelity.
1. Employee Information
Name First, M.I., Last Social Security Number
Street Address
City State/Province ZIP/Postal Code Employer Name
2. Salary Reduction Election
Subject to the requirements of the Defined Contribution Retirement Plan, of the above-named employer, I authorize the percentage OR dollar
amount listed below to be withheld from my pay each pay period and contributed to my Defined Contribution Retirement Plan account as a salary
reduction contribution.
Insert percentage.
Percentage of my pay
%
.
OR
Insert single-
sum amount
Amount per pay period
$
.
OR
a one-time deferral
contribution of
Amount
$
.
as of
(Insert date on which you want this
amount withheld from your pay.)
Date MM DD YYYY
I do not want any deferrals withheld from my pay going forward and/or I elect to stop contributions as of
Date MM DD YYYY
3. Maximum Salary Reduction
I understand that the total amount of my salary reduction contributions in any calendar year cannot exceed the applicable amounts listed below.
Tax Year Annual Deferral Amount Annual Catch-up Amount*
2020 $19,500 $6,500
2021 $19,500 $6,500
*Employees age 50 or older by the end of the calendar year may make additional elective deferral contributions annually.
4. Date Salary Reduction Begins
I understand that my salary reduction contributions will start as soon as permitted under the Defined Contribution Retirement Plan and as soon as
administratively feasible. Or, if I prefer later, I choose the following date for my salary reductions to begin.
This date must be on or
after the date you sign
this Agreement.
Date MM DD YYYY
5. Duration of Election
By signing below, I:
Understand this Salary Reduction Agreement replaces any earlier agreement and will remain in effect as long as I remain an Eligible Employee
under the Defined Contribution Retirement Plan, until I provide a request to end my salary reduction contributions, or until I provide a new Salary
Reduction Agreement.
PRINT EMPLOYEE NAME
EMPLOYEE SIGNATURE DATE MM/DD/YYYY
SIGN
X X
