Incoming Rollover Instructions Directed Account Plan #21622

Transcription

1 Incoming Rollover Instructions Directed Account Plan #21622 If you are a current Directed Account Plan (DAP) participant or a former DAP participant, you may roll over assets from other accounts into the DAP based on the following guidelines: 1) Traditional IRA assets can be rolled into the DAP. 2) Assets that were rolled out of the DAP into a Traditional IRA can be rolled back into the DAP. 3) Roth IRA assets cannot be rolled into the DAP. However, Roth 401(k)/403(b) assets can be rolled into the DAP. 4) Nondeductible IRA contributions cannot be rolled into the DAP. 5) The earnings attributable to nondeductible IRA contributions can be rolled into the DAP. If you have a balance in a former employer s retirement plan or Individual Retirement Account (IRA), you may want to consider consolidating your assets in the Directed Account Plan. Keeping your retirement savings in a single plan can help simplify performance tracking, provide greater convenience in making investment changes, and minimize paperwork. Rolling money into the Directed Account Plan is a three-step process. Please follow these instructions to ensure that your rollover is completed in a timely and accurate manner. Please note that failure to follow these instructions may result in a delay in the processing of your request and may jeopardize your ability to roll over your distribution. 1. Complete Your Rollover Application Please complete the attached Incoming Rollover Contribution Application, and attach any supporting documents. 2. Mail the Information Mail the Incoming Rollover Contribution Application along The Directed Account Plan with a copy of your latest statement from the financial 3221 McKelvey Road institution currently holding the funds to: Suite 105 Bridgeton, Missouri Please include all the information requested. Incomplete forms may be returned and may jeopardize your ability to roll over your distribution. 3. Request Your Distribution from Your Previous Employer-Sponsored Plan or Eligible IRA There are two distribution check payment options: 1. Direct Rollover: The check can be made payable directly to Fidelity Investments Institutional Operations Company, Inc. (or FIIOC) for the benefit of [YOUR NAME]. The check must be from the distributing trustee or custodian. (Personal checks are not acceptable.) Do not endorse the check. Important: This type of rollover avoids automatic federal income tax withholding. It also avoids the possible 10% early withdrawal penalty if you are under age 59½. 2. Indirect Rollover: If the distribution was originally made payable directly to you, you must send your rollover contribution via a certified check or money order only for the amount you are rolling over. (Personal checks are not acceptable.) Important: If your distribution is initially received as a check made payable to you, your rollover must be completed within 60 days of the date of the distribution. Your previous administrator will be required to withhold federal income taxes and possibly state taxes. As a result, you will not be able to roll over 100% of your eligible distribution unless you have extra savings available to make up the amount withheld. You must also roll over that amount within 60 days of receipt of your distribution. If you do not make up the amount withheld, that amount will be considered a withdrawal from the previous program and will be subject to ordinary income taxes and possibly to a 10% early withdrawal penalty. Once your application is received by the Directed Account Plan, and your rollover check is processed, you can log on to Fidelity NetBenefits at to view your rollover contribution and investment elections. If you have any questions about rollover contributions, call the Plan Office at Please allow time for your check to reach Fidelity. Please be sure you have beneficiary information for the Plan on file. To select or change your beneficiary designation for the Directed Account Plan, you can log on to Fidelity NetBenefits at and click Beneficiaries in the My Profile section. If you do not have Internet access, call the Directed Account Plan Service Center toll free at TWADAP ( ) and request a Beneficiary Designation Form. Page 1 of 6 3.DI-C-740A.113

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3 Section 1 Participant Information Please Print Participant s Name (First, Middle Initial, Last) Incoming Rollover Contribution Application Directed Account Plan # Social Security Number ( ) - Street Number Street Name Daytime Phone Number City State ZIP Country / / / / Birth Date Hire Date Address Section 2 Rollover Contribution Information Please complete the boxes at the end of this section. If you are not sure of the plan type, please contact your prior Plan Sponsor for verification. An incorrect plan type could invalidate your rollover. ACCEPTABLE ROLLOVER FUNDS The Plan will accept taxable and non-taxable money from the following types of employer-sponsored plans: Qualified plans (such as 401(k), Roth 401(k)/403(b), profit-sharing, and money purchase pension plans) Individual Retirement Accounts (IRAs) UNACCEPTABLE ROLLOVER FUNDS The Plan cannot accept distributions from the following types of plans or accounts: Governmental 457(b) plans Coverdell Education IRAs Roth IRAs SIMPLE IRAs Simplified Employee Pension Plans (or SEP IRAs) IRAs in which you have made non-deductible IRA contributions In addition, distributions to a beneficiary (other than a spousal beneficiary), distributions to a former spouse under a qualified domestic relations order (QDRO), distributions made over life expectancy or a period of ten years or more, hardship distributions, and mandatory age 70½ distributions are not eligible for rollover into the Plan. Non-taxable (or after-tax) distributions other than from a qualified plan may not be rolled into the Plan. In-kind distributions of employer stock will not be accepted. If you hold employer stock in your prior employer s plan, the stock must be sold and the proceeds rolled over in cash. PLEASE COMPLETE BOTH BOXES BELOW: 1. Your Estimated Contribution Amount: Pre-tax dollars $ After-tax dollars $ Roth 401(k)/403(b) dollars $ Total $ 2. Plan type of the origin of this rollover (please check one). If you are not sure of the plan type, please contact your prior Plan Sponsor for verification. An incorrect plan type could invalidate your rollover. Qualified plan (such as 401(k), Roth 401(k)/403(b), profit-sharing, and money purchase pension plan) Individual Retirement Account (IRA) Page 3 of 6 For Fidelity Use Only: NIGO DC

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5 Section 3 Investment Elections You may choose as many investment options as you wish from the options in the Plan. The quantity and selection of available investment options are determined by the Plan Sponsor. Please indicate your investment elections in whole percentages among the investment options shown below (the total percentage must equal 100%). Your investment elections below will apply only to this rollover contribution. If your investment elections do not total 100%, your documentation and check will be returned to you. Please be sure to read the mutual fund prospectuses before choosing your investment options. Prospectuses for the funds are available from the Directed Account Plan Service Center by calling TWADAP ( ). Investment Option Level One: The Model Portfolios Fund Code Percentage Investment Option Fund Code Level Three: Fidelity Mutual Funds cont d Page 5 of 6 Percentage Retirement Model Portfolio OOLS % Fidelity Equity-Income Fund Class K 2085 % Conservative Model Portfolio OJQT % Fidelity Europe Capital Appreciation Fund* 0341 % Moderate Model Portfolio OJQU % Fidelity Europe Fund* 0301 % Aggressive Model Portfolio OJQV % Fidelity Export and Multinational Level Two: The Core Options 2087 % Stable Value Option OJQW % Fidelity Fifty 0500 % Value Stock Option OJQX % Fidelity Focused Stock Fund 0333 % Equity Index Option OJQY % Fidelity Four-in-One Index Fund 0355 % Growth Stock Option OJQZ % Fidelity Fund Class K 2088 % International Stock Option* OJRA % Fidelity Global Balanced Fund* 0334 % Diversified Small Company Stock Option OJRB % Fidelity Government Income Fund 0054 % Level Three: Fidelity Mutual Funds Fidelity Growth & Income Portfolio Class K 2089 % Fidelity Balanced Fund Class K 2077 % Fidelity Growth Company Fund Class K 2090 % Fidelity Blue Chip Growth Fund Class K 2078 % Fidelity Growth Discovery Fund Class K 2091 % Fidelity Blue Chip Value Fund 1271 % Fidelity Growth Strategies 2076 % Fidelity Canada Fund* 0309 % Fidelity High Income Fund* 0455 % Fidelity Capital & Income Fund* 0038 % Fidelity Independence Fund Class K 2092 % Fidelity Capital Appreciation Fund Class K 2079 % Fidelity Inflation-Protected Bond Fund 0794 % Fidelity China Region Fund* 0352 % Fidelity International Capital Appreciation Fund* Fidelity Contrafund Class K 2080 % Fidelity International Discovery 0335 % 2093 % Fidelity Convertible Securities Fund 0308 % Fidelity International Small Cap Fund* 0818 % Fidelity Disciplined Equity Fund Class K 2081 % Fidelity Investment Grade Bond Fund 0026 % Fidelity Diversified International 2082 % Fidelity Japan Fund* 0350 % Fidelity Dividend Growth Fund Class K 2083 % Fidelity Japan Smaller Companies Fund* 0360 % Fidelity Emerging Asia Fund* 0351 % Fidelity Large Cap Growth Fund 0763 % Fidelity Emerging Markets 2084 % Fidelity Large Cap Stock Fund 0338 % Fidelity Equity Dividend Income Fund Class K 2086 % Fidelity Latin America Fund* 0349 % *Shareholders may be subject to certain short-term trading fees. Please consult the prospectus for further information. 3.DI-C-740A DC

6 Section 3 Investment Elections Continued Level Three: Fidelity Mutual Funds cont d Fidelity Leveraged Company Stock Fidelity Low-Priced Stock Fund Class K* Level Three: Fidelity Mutual Funds cont d 2094 % Fidelity Stock Selector All Cap Fund Class K 2095 % Fidelity Stock Selector Large Cap Value Fund 2101 % 0708 % Fidelity Magellan Fund Class K 2096 % Fidelity Stock Selector Mid Cap Fund 2412 % Fidelity Mega Cap Stock Fund 0361 % Fidelity Stock Selector Small Cap Fund* 0336 % Fidelity Mid-Cap Stock 2097 % Fidelity Strategic Dividend & Income Fund 1329 % Fidelity Mid Cap Value Fund* 0762 % Fidelity Strategic Income Fund 0368 % Fidelity Money Market Trust Retirement Government Money Market Portfolio 0631 % Fidelity Telecom and Utilities Fund 0311 % Fidelity Nasdaq Composite Index Fund* 1282 % Fidelity Total Bond Fund 0820 % Fidelity New Markets Income Fund* 0331 % Fidelity Trend Fund 0005 % Fidelity New Millennium Fund 0300 % Fidelity Value Discovery Fund Class K 2103 % Fidelity Nordic Fund* 0342 % Fidelity Value Fund Class K 2102 % Fidelity OTC Portfolio Class K 2098 % Fidelity Value Strategies Fund Class K 2104 % Fidelity Overseas 2099 % Fidelity Worldwide Fund* 0318 % Fidelity Pacific Basin Fund* 0302 % Spartan 500 Index Fund Investor Class 0650 % Fidelity Puritan Fund Class K 2100 % Spartan Extended Market Index Fund Investor Class* Fidelity Real Estate Income Fund* 0833 % Spartan International Index Fund Investor Class* Fidelity Real Estate Investment Portfolio* 0303 % Spartan Total Market Index Fund Investor Class* Fidelity Small Cap Discovery Fund* 0384 % Spartan U.S. Bond Index Fund Investor Class 0398 % 0399 % 0397 % 0651 % Fidelity Small Cap Growth Fund* 1388 % Level Four: Fidelity BrokerageLink Fidelity Small Cap Stock Fund* 0340 % Fidelity BrokerageLink BLNK % Fidelity Small Cap Value Fund* 1389 % TOTAL 100% Note: Any investment elections chosen on this form will take precedence over any other investment election that Fidelity Investments may have on its system for a rollover contribution. *Shareholders may be subject to certain short-term trading fees. Please consult the prospectus for further information. Section 4 Participant Certification I authorize the investment elections for this rollover and acknowledge that I have received information detailing my available investment options. I certify that this rollover amount is composed only of money from acceptable sources listed under Section 2 above, and I have completed the information regarding the source of this money to the best of my knowledge. Also, if the distribution check was made payable to me, I understand that this rollover must be received and deposited to my account within 60 days of my receipt of the distribution. I understand that once invested, these monies will be subject to the terms that govern the Directed Account Plan. Signature of Participant Date Fidelity Investments Institutional Operations Company, Inc DI-C-740A.113 Page 6 of 6