Irrevocable Contribution Form and Letter of Instruction

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Questions? Go to FidelityCharitable.org or call 800-952-4438.

1.851030.127 018331301

Irrevocable Contribution Form and

Letter of Instruction

Use this form to make irrevocable contributions to a Fidelity Charitable® Giving Account® or a Giving Account® that is enrolled in

the Charitable Investment Advisor Program (CIAP). All required fields are marked with an asterisk (*).

Assets held at Fidelity Investments®: Complete sections 1, 2A, 3, and 5.

Assets held outside of Fidelity Investments®: Complete sections 1, 3, 4, and 5.

Checks, wires, or stock certificates: Complete sections 1, 2B, 3, and 5.

To contribute restricted stock, stock from a Dividend Reinvestment Plan (DRIP), or other non-publicly traded assets please contact

Fidelity Charitable® at 800-262-6039.

1. Giving Account and Donor Information

Who is making this irrevocable contribution to Fidelity Charitable? The information provided will be used to generate

a tax receipt to the person or entity (e.g., trust, partnership, or corporation) making the irrevocable contribution.

Giving Account Number* Giving Account Name

Account Holder Third-Party Donor

First Name* M.I. Last Name*

Entity

Entity Legal Name (e.g., The Smith Family Trust)

Contact Information

Preferred Phone*

Address*

City* State/Province* ZIP/Postal Code* Country*

Social Security or Tax Identification Number*

U.S. citizen U.S. resident alien

Form continues on next page.

Check one.

Phone numbers are

for questions about

this request only; they

will not update your

Fidelity Charitable

contact information.

Reset

Save

2. Irrevocable Contribution

Complete the applicable section below. If your employer matches charitable contributions to charities with donor-advised fund programs,

please include the appropriate company paperwork.

Fidelity Charitable is not able to process irrevocable contribution requests from Fidelity® IRA accounts. Alternatively, please log in to

Fidelity.com and request a one-time distribution from your IRA account to either a nonretirement Fidelity® account or via EFT to your

personal bank account. Once the distribution has settled, then log in to FidelityCharitable.org and process an irrevocable contribution to

your Giving Account.

2A. Assets from a Fidelity Investments Account

I. Cash

Contribute cash held at Fidelity

Cash Transfer Amount* Fidelity Account Number*

II. Stocks, Securities, or Mutual Funds

Contribute the following stocks, securities, money market funds, and mutual funds held at Fidelity. All trades are

transacted in whole shares. If a partial share is provided, Fidelity Charitable will round down to the next whole

number unless the entire position is being contributed.

Description of Assets* Symbol* Fidelity Account Number*

Number of Shares* Lot Acquisition Date Optional MM DD YYYY Lot Acquisition Cost Optional

Description of Assets* Symbol* Fidelity Account Number*

Number of Shares* Lot Acquisition Date Optional MM DD YYYY Lot Acquisition Cost Optional

By signing this form, You (an account owner of a Fidelity brokerage account) are 1) authorizing National Charitable Services LLC (“NCS”) to accept instructions

from You and/or your Authorized Interested Party/Agent/Advisor (“Your Agent”) to transfer cash and securities from a Fidelity nonretirement brokerage account

to Fidelity Charitable, as a charitable contribution, without requiring additional written instructions from You; and 2) authorizing Fidelity Brokerage Services LLC

and National Financial Services LLC to act on such instructions directly from NCS without additional authorizations from You. This authorization shall apply only

to nonretirement Fidelity brokerage accounts on which You are registered as an owner (“Fidelity Account”), and in the case of Your Agent, for which Your Agent

has been authorized with full trading authority or asset movement authorization level 1 or 2. This authorization will be relied upon only when You or Your Agent

provides contribution instructions to Fidelity Charitable. Note: This is a one-time authorization.

2B. Cash and Stock Certiﬁcates held outside of Fidelity

III. Check or Wire

Check Amount*

Make checks payable to Fidelity Charitable and reference the

Giving Account number or name in the memo section.

Wire Amount* Bank Name*

Fidelity Charitable will not initiate this wire transfer. Please see page 6 for wire instructions.

IV. Stock Certiﬁcates Held in Personal Possession

Contribute the following stock certificates. Note: Please obtain a Medallion Signature Guarantee stamp on the stock

certificate. When endorsing the certificate(s) write “National Financial Services LLC” between the words “appoint” and “attorney” in

the space provided on each certificate. Date and Sign the certificate exactly as your name(s) appears on the front. Mail certificate

along with this form via registered mail.

Name of Stock* Number of Shares*

Fidelity Charitable will not

accept contributions of

currency or certain cash-like

monetary instruments, includ-

ing cashier’s checks, treasurer’s

checks, bank checks, official

checks, bank drafts, traveler’s

checks, or money orders.

Form continues on next page.

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Enter specific share

identification, if

applicable. If you

do not specify tax

lots, irrevocable

contributions will

be processed using

the account’s default

disposal method.

Note: If you are

contributing more

than two securities, a

copy of this page can

be attached.

3. Investment Selection

A. Managed Investments

This section is only for any Giving Account enrolled in the Charitable Investment Advisor Program (CIAP).

Please note: All contributions can be transferred directly to the managed account. Any contributions that are

transferred to the Fidelity Z97-000442 will be transferred in kind to the advisor-managed account and will only be

liquidated if the brokerage account is not custodied with Fidelity NFS.

If you would like your contribution to be allocated to the Giving Account investment pools, as opposed to the

managed account, please proceed to section B below.

Managed Account Number ______________________

B. Investment Pool Selection

Please recommend how you would like to allocate your irrevocable contribution. If you do not make a

recommendation, your contribution will be allocated to reflect the current pool allocation of your Giving Account. If

your account is unfunded, your contribution will be allocated to the Asset Allocation 20% Equity Pool.

Please Note: If a pool is selected below, your asset(s) will be liquidated and allocated to the selected pool(s).

Allocate this irrevocable contribution in the same percentages as my current investment pools.

Allocate this irrevocable contribution as follows:

Option 1: Charitable Legacy Pool Percentage of total

For donors seeking an “all-weather” asset

allocation pool with exposure to both tradi-

tional and non-traditional asset classes.

Charitable Legacy

Option 2: Asset Allocation Pools

Percentage of total

For donors seeking instant diversification to

multiple asset classes in a single investment.

Asset Allocation 85% Equity

Asset Allocation 70% Equity

Asset Allocation 60% Equity

Asset Allocation 50% Equity

Asset Allocation 40% Equity

Asset Allocation 30% Equity

Asset Allocation 20% Equity

Option 3: Sustainable and Impact

Investing Pools

Percentage of total

For donors who seek strategies that consider

social and environmental factors, while

emphasizing financial returns.

Stock

Sustainable U.S. Index

Sustainable U.S. Index Access

Sustainable International Index

Environmental Impact Access

Bond

Sustainable U.S. Bond Index

Option 4: Single Asset Class Pools Percentage of total

For donors who want to build a custom strat-

egy combining pools with specific investment

objectives for Giving Account balances.

Domestic Stock

U.S. Equity

U.S. Equity Access

Total Market Index

Foreign Stock

International Equity

International Equity Access

International Index

Bond

Fixed Income

Fixed Income Access

U.S. Bond Index

Short-Term Fixed Income Access

Inflation Protected Bond Index

Money Market

COMBINED TOTAL MUST EQUAL:

1 0 0 %

Check one.

Choose from option

1, 2, 3, 4, or a

combination of the

four. The combined

total must equal

100%.

Form continues on next page.

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LETTER OF INSTRUCTION

4. Contribute Securities or Mutual Funds

†

Held at a Financial Institution

Other than Fidelity

Option 1: I will initiate the transfer of assets by completing

the following steps:

If enrolled in CIAP, and the CIAP account is not custodied

with National Financial Services, deliver directly to the

managed account. All others see the following instructions.

Contact the financial institution directly to obtain their

required procedures and forms, and then complete and

deliver with the following instructions:

Deliver to: DTC 0226 Acct Z97000442

FBO: ACCT#_______

2) Complete this form and mail or fax to Fidelity

Charitable. Fax: 877-665-4274. Note: A separate form

must be filled out for transfers from separate financial

institutions.

Option 2: I authorize Fidelity Charitable

to initiate the transfer of assets by

completing the following steps:

1) Complete this form and mail or fax to

Fidelity Charitable. Fax: 877-665-4274.

2) Include a copy of the most recent

account statement from which the

assets will be transferred.

TO:

Fidelity Charitable Giving Account Number*

FROM:

Delivering Firm Name* Advisor/Broker Name*

Preferred Phone* Extension

Address*

City* State/Province* ZIP/Postal Code* Country*

Account Number at Delivering Firm*

TRANSFER:

Number of Shares* Approximate Dollar Amount if known

Description of Assets/Name of Security*

Lot Acquisition Date Optional MM DD YYYY Lot Acquisition Cost Optional Symbol*

Number of Shares* Approximate Dollar Amount if known

Description of Assets/Name of Security*

Lot Acquisition Date Optional MM DD YYYY Lot Acquisition Cost Optional Symbol*

†

Note: If you are

transferring mutual

funds, please select

option 2. Fidelity

Charitable must initiate

the transfer of mutual

funds on your behalf

and will take approx-

imately three to six

weeks to complete.

Page 4 of 61.851030.127 018331304

Form continues on next page.

Tax lots entered

are provided to the

ﬁrm from which

the assets are

transferring. Fidelity

Charitable cannot

guarantee that

those tax lots will be

delivered at the time

of transfer.

Note: By providing

your Advisor’s name

and phone number,

you are authorizing

Fidelity Charitable to

release information

regarding this

transfer to your

Advisor for the pur-

pose of completing

the transfer.

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5. Signatures and Dates

By signing below, you:

• Acknowledge that you have read the current Fidelity Charitable

Program Guidelines and (for CIAP account holders) the Charitable

Investment Advisor Program: Investment Policies and Guidelines

and agree to the terms and conditions describedtherein.

• Understand that any contribution, once accepted by the Trustees,

represents an irrevocable contribution to Fidelity Charitable and

is not refundable.

• Approve the Letter of Authorization if Section 2A is completed.

• Acknowledge that you did not receive goods or services in

exchange for, or in consideration of, this irrevocable contribution.

• Understand that, if you are a third-party contributor, you may be

eligible for a tax deduction, but you will not obtain any Giving

Account advisory privileges.

• Certify that to the best of your knowledge, all information pre-

sented in connection with this form is accurate.

• Will promptly notify Fidelity Charitable in writing of any changes.

Donor or Authorized Party Name*

Date* MM DD YYYY

DATE

Signature*

SIGN

Additional Signatory Name* (if dual signatures are required by firm)

Date* MM DD YYYY

DATE

Signature*

SIGN

Form continues on next page.

AUTHORIZED FOR FIDELITY USE ONLY

MEDALLION SIGNATURE GUARANTEE

AUTHORIZED FOR FIDELITY USE ONLY

MEDALLION SIGNATURE GUARANTEE

Under the policies of Fidelity Charitable, and in accordance with the anti–money laundering regulations applicable to the various

financial institutions that provide financial services to Fidelity Charitable, we obtain, record, and may verify information that identifies

each person who establishes a Giving Account at Fidelity Charitable, and other people who contribute or have access to the

Giving Account.

What this means: Fidelity Charitable will ask for the name, address, Social Security number, date of birth, and other information that will

allow us to identify people with access to the Giving Account. We may also ask to see individual driver’s licenses or other identifying

documents, and we may verify the information we obtain.

Note: For FCCS

Advisors only

(AMA ¹ or ²).

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Fidelity Charitable is the brand name for the Fidelity Investments® Charitable Gift Fund, an independent public charity with a donor-

advised fund program. Various Fidelity companies provide services to Fidelity Charitable. The Fidelity Charitable name and logo, and

Fidelity are registered service marks of FMR LLC used by Fidelity Charitable under license. Giving Account is a registered service mark of

the Trustees of Fidelity Charitable. 880597.6.0

Mail this form to Fidelity Charitable: OR Fax the form to Fidelity Charitable:

Regular mail

Fidelity Charitable

PO Box 770001

Cincinnati, OH 45277-0001

Overnight mail

Fidelity Charitable

100 Crosby Parkway KC1D-FCS

Covington, KY 41015-4325

877-665-4274

If the delivering broker requires an original signature,

you must mail the form to Fidelity Charitable. We

cannot accept an original signature via fax.

Note to Broker-Dealers: For delivery instructions, visit FidelityCharitable.org/docs/broker-dealer-instructions.pdf.

Delivery Options

Delivery instructions for contributing assets held outside Fidelity Investments:

DTC-Eligible Securities

Deliver to DTC Clearing 0226

Account Number: Z97-000442

FBO: CGF# and Account Name: _ _ _ _ _ _ _ _ _ _

Wire Instructions

Wire to: JPMorgan Chase Bank

ABA: 021000021

For Credit to: NFS 066196-221

FBO: Fidelity Charitable Z97000442

Memo: CGF# and Account Name: _ _ _ _ _ _ _ _ _ _

Please note: Fidelity Charitable will not initiate wire transfers.

The wire will be rejected if necessary account name and account numbers are not provided, which may incur a fee from your bank.