1. GENERAL INSTRUCTIONS
This form is for plans that DO NOT require spousal consent for a beneficiary designation.
Please complete this form and sign it on the back. In the future, you may revoke the beneficiary designation and designate a different
beneficiary by submitting a new Beneficiary Designation Form to Fidelity.
Mailing instructions: Return this form in the enclosed postage-paid envelope or to
Fidelity Investments, P.O. Box 770002, Cincinnati, OH 45277-0090
If you wish to send your form via overnight service, please send it to
Fidelity Investments, Mailzone KC1E, 100 Crosby Parkway, Covington, KY 41015
Questions? Call Fidelity Investments at 1-800-343-0860, Monday through Friday, from 8:00 A.M. to midnight ET, or visit us at
2. DESIGNATING YOUR BENEFICIARY(IES)
You are not limited to two primary and two contingent beneficiaries. To assign additional beneficiaries, or to designate a
more complex beneficiary designation, please attach, sign, and date a separate piece of paper.
When designating primary and contingent beneficiaries, please use whole percentages and be sure that the percentages
for each group of beneficiaries total 100%. Your primary beneficiary cannot be your contingent beneficiary. If you designate a trust as a
beneficiary, please include the date the trust was created, and the trustee's name.