Use this form to direct your employer to defer part of your compensation to your company’s Fidelity SIMPLE IRA Plan, or to change your existing Salary Reduction Agreement. Refer to Section 3(A) of the Fidelity SIMPLE IRA Summary Description to determine when changes may be made to an existing Salary Reduction Agreement.

Please give the completed form to your employer and retain a copy of this form for your records. This form does not need to be returned to Fidelity.

Employee Information

Salary Reduction Election

Subject to the requirements of the SIMPLE IRA 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 SIMPLE IRA as a salary reduction contribution.

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. 

*Employees age 50 or older by the end of the calendar year may make additional elective deferral contributions annually.

Date Salary Reduction Begins

I understand that my salary reduction contributions will start January 1, 2025

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 SIMPLE IRA Plan, until I provide my employer with a request to end my salary reduction contributions, or until I provide a new Salary Reduction Agreement as permitted under my employer’s SIMPLE IRA Plan.