Fidelity Omnibus Account Certification Form

You may return the form(s) to us by mail to Fidelity Investments, P.O. Box 770001, Cincinnati, OH 45277-0039.
If you have any questions, please call us at 1-800-544-4774, from 8:00 a.m. to 8:00 p.m. ET.

Full legal name _______________________________________________________________________________________________

Mailing address

Street

Daytime Telephone Number (

City
)

State

Zip

Fidelity Account Number:

Important Note: If this account holds qualified retirement plan assets, please call 1-800-544-4774, from 8 a.m. to 8 p.m. ET, as your account
may be incorrectly registered.
Omnibus Account Certification
A Pooled or Omnibus Account is a single account that pools the holdings of more than one beneficial owner, whose identities are not disclosed to
Fidelity, in which the beneficial owners have the ability to effect transactions, and for which sub-accounting is performed by the omnibus account
holder or a third party. The ability to effect transactions is defined as a participants ability to effect any transaction, including but not limited to,
directing a payroll contribution, requesting an exchange, a loan, a withdrawal (including a hardship withdrawal), a transfer, redemption, and autorebalancing, as well as the ability to direct investment activity and ability to trade in the account.
Please verify the structure of your account by checking one (1) of the following certifications and return this form to Fidelity in the enclosed postage
paid envelope.
I certify that the account listed above is not a pooled account.
OR
I certify that the account listed above is a pooled account as defined above.

DISCLOSURE:
As account owner, trustee or authorized person for this account, I hereby certify that the above information is accurate and correct as of the
indicated date.

AUTHORIZED SIGNATURE

X
ACCOUNT OWNER, TRUSTEE OR
AUTHORIZED PERSON

Date

Fidelity Investments is a registered trademark owned by FMR Corp. Accounts are carried with our affiliate,
National Financial Services LLC, a member of the New York Stock Exchange and other principal exchanges.
Fidelity Brokerage Services LLC, National Financial Services LLC, Members NYSE, SIPC
P.O. Box 770001, Cincinnati, OH 45277-0039

385111.2.0

1.807706.101

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NR-CERT-FM-0607

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6/12/07 2:41:31 PM