Self-Employed 401(k) - Contribution Remittance Form at a glance
What it is: Self-Employed 401(k) - Contribution Remittance Form.
Who signs: Print the Plan Administrator or Employer Name, then the Plan Administrator or Employer signs and enters the date as MM/DD/YYYY.
A filled-in Self-Employed 401(k) - Contribution Remittance Form example: a self-employed owner remits one deposit
How to fill out Self-Employed 401(k) - Contribution Remittance Form, box by box
Employer Information
Under 1. Employer Information, enter the Employer Name (i.e., Company Name), the Employer Tax ID Number, the Plan Administrator, the Daytime Phone and the Extension.
Contribution Information
Enter the Employee Name and the Fidelity Account Number, then the Employee 401(k) Contribution as Current Year (CYP) or Prior Year (PYP), the Employer Profit Sharing Contribution (CCR) and the Total Contribution. For the Employer Profit Sharing Contribution (CCR)*, to the extent applicable, include any safe harbor nonelective contributions.
Be sure to indicate how to allocate contributions for each plan participant to the applicable contribution sources: Employee 401(k) and/or Employer Profit Sharing Contributions.
If Fidelity is unable to allocate contributions to the sources indicated, Fidelity will deposit them as Employer Profit Sharing Contributions, and Fidelity will then contact you on how to resolve them.
All deposits may be subject to a four-business-day clearing period.
It is your responsibility to separately account for each of the two different contribution types to ensure that applicable annual limits are not exceeded.
Contributions will be deposited in each participant's core account.
Authorization
Under 3. Authorization, by signing, you understand that you are required to comply with applicable contribution limits and deadlines, and you hereby authorize Fidelity Brokerage Services LLC ("Fidelity") to deposit the dollar amounts to the designated account(s), as instructed.
By signing, you understand that it is your responsibility to allocate contributions to the appropriate employee and contribution source correctly. Failure to clearly designate a contribution type may result in the entire check being returned to you for further instructions, for which Fidelity will not be responsible for delay(s) in contributions.
By signing, you agree to fully indemnify and hold Fidelity and its affiliates harmless for any liability that may arise from Fidelity acting upon your instructions.
Print the Plan Administrator or Employer Name, then the Plan Administrator or Employer signs and enters the date as MM/DD/YYYY.
More rules for Self-Employed 401(k) - Contribution Remittance Form
Please keep a copy of your completed contribution remittance form for your records.
Questions? Go to Fidelity.com/smallbusiness or call 800-343-3548.
Common questions about Self-Employed 401(k) - Contribution Remittance Form
Where do I file it?
Make check(s) payable to Fidelity Investments and mail to: Regular mail: Fidelity Investments, P.O. Box 770001, Cincinnati, OH 45277-0003. Overnight mail: Fidelity Investments, 100 Crosby Parkway, KC1H, Covington, KY 41015. Use this form to submit contribution deposits to your Fidelity Self-Employed 401(k) Plan account(s). Type on screen or fill in using CAPITAL letters and black ink. If you need more room for information, make a copy of this form.
Sources
[1] Self-Employed 401(k) - Contribution Remittance Form (06/17), Fidelity Investments (the Official source link on this page).
