attorney in fact affidavit and indemnification form

Cover Sheet

GENERAL INSTRUCTIONS

ow to use t is Durable Power of ttorne or :is e owe o tto ne o e se to est is n tto ne in ct o o wo ce

s in s n s ension n s n e t n we e n s ns w ic e eco e t i e it o ce e ices i e it T P A or o o o I R r A o s

IRA or r o o

P r r Po r o A or or r I or oThis POA o will give the individual(s) you designate as your Attorney(s)-in-Fact the authority to manage your employer sponsored bene ts listed on the o POA. Depending on your elections, your Attorney(s)-in-Fact may be able to request information about your plan bene ts, execute transactions, and designate or update your plan bene ciaries as permitted by the terms of the plan. Please note that you must specifically grant your Attorney(s)-in-Fact the authority to designate or change your beneficiary designations.

GUIDELINES FOR COMPLETING THE DURABLE POWER OF ATTORNEY FORM

Participant:

• Please complete all required sections of the Durable Power of Attorney Form.• Please sign and date in the presence of a o r who must provide his/her acknowledgment in accordance

with applicable state s.• If you are designating more than one Attorney(s)-in-Fact, please complete and submit a separate Durable Power of

Attorney Form for each Attorney(s)-in-Fact. Please ensure that you have completed the applicable sections on thisform regarding how multiple agents should act.

• If you are granting your Attorney(s)-in-Fact authority related to plans sponsored by more than one employer, pleasecomplete and submit a separate Durable Power of Attorney Form for each employer.

tto ne s in ct:• Please sign and date in the presence a o r who must provide his/her acknowledgment in accordance

with applicable state s.

Note: Please note that this orm is not applicable for residents of New York. Residents of certain states (CA, ME, MI or PA) may be subject to additional requirements included at the end of this form. You are responsible for ensuring compliance with state’s requirements. Review carefully with a trusted legal professional before you sign.

Questions? Call 800-835-5097

Cover Sheet

GENERAL INSTRUCTIONS

ow to use t is Durable Power of ttorne or :is e owe o tto ne o e se to est is n tto ne in ct o o wo ce

s in s n s ension n s n e t n we e n s ns w ic e eco e t i e it o ce e ices i e it T P A or o o o I R r A o s

IRA or r o o

P r r Po r o A or or r I or oThis POA o will give the individual(s) you designate as your Attorney(s)-in-Fact the authority to manage your employer sponsored bene ts listed on the o POA. Depending on your elections, your Attorney(s)-in-Fact may be able to request information about your plan bene ts, execute transactions, and designate or update your plan bene ciaries as permitted by the terms of the plan. Please note that you must specifically grant your Attorney(s)-in-Fact the authority to designate or change your beneficiary designations.

GUIDELINES FOR COMPLETING THE DURABLE POWER OF ATTORNEY FORM

Participant:

• Please complete all required sections of the Durable Power of Attorney Form.• Please sign and date in the presence of a o r who must provide his/her acknowledgment in accordance

with applicable state s.• If you are designating more than one Attorney(s)-in-Fact, please complete and submit a separate Durable Power of

Attorney Form for each Attorney(s)-in-Fact. Please ensure that you have completed the applicable sections on thisform regarding how multiple agents should act.

• If you are granting your Attorney(s)-in-Fact authority related to plans sponsored by more than one employer, pleasecomplete and submit a separate Durable Power of Attorney Form for each employer.

tto ne s in ct:• Please sign and date in the presence a o r who must provide his/her acknowledgment in accordance

with applicable state s.

Note: Please note that this orm is not applicable for residents of New York. Residents of certain states (CA, ME, MI or PA) may be subject to additional requirements included at the end of this form. You are responsible for ensuring compliance with state’s requirements. Review carefully with a trusted legal professional before you sign.


This D urable Power of Attorney Form ( " POA" ) , may be used to establish an Attorney( s) -in-Fact for your workplace savings plan( s) , pension plan( s) , and health and welfare plan( s) ( " Plans" ) which are recordkept by Fidelity W orkplace S ervices, L L C ( " Fidelity" ) . This POA form does not apply to Fidelity Individual Retirement Accounts "IRA" or personal investment accounts.

EFFECT OF THE DURABLE POWER OF ATTORNEY FORM

Effect:Upon acceptance of the Durable Power of Attorney Form submitted to Fidelity, Fidelity will to notify you and the Attorney(s)-in-Fact. Informational or transactional requests made by the Attorney(s)-in-Fact will be reviewed after notification of acceptance.

Powers:hen accepted, this POA may give your designated Attorney(s)-in-Fact the authority to (among other actions)

• make inquiries and conduct transactions on your benefits with the same authority that you have• manage and initiate distributions of your benefits and• if so authorized, update your plan beneficiaries.

Duration:hen accepted, the authority you designate to the Attorney(s)-in-Fact will generally remain in effect until your death, even

if you become incapacitated, unless you revoke the designation or a court appointed guardian or conservator terminates the designation. Upon notice of your death, Fidelity will terminate the authority given to your designated Attorney(s)-in-Fact. You may amend or change your POA designations by executing and submitting a new Durable Power of Attorney for review and acceptance. You have the right to revoke or terminate your POA designations at any time, by submitting a letter of revocation or termination to Fidelity which contains your notarized signature.

No T r o P A or r r o r r o o or r o or ro r or o o P A

r o o r r or o P A o o o o r or N r or o or r or o or

o o r r o o o P A r r or or o o

WHERE TO SEND THE DURABLE POWER OF ATTORNEY FORM

Please return the completed forms to

For overnight delivery

Fidelity Investments Attention ualification Services 1 Crosby Parkway, C1F Covington,

Y 41 15

If you have questions, please contact your Benefits Service Center toll-free at - 35-5

Cover Sheet

Forms begin on next page.

For regular mail delivery

Fidelity Investments Attention ualification Services P.O. Box 3 Cincinnati, OH 452 - 65


Effect:Upon acceptance of the Durable Power of Attorney Form submitted to Fidelity, Fidelity will notify you and the Attorney(s)-in-Fact. Informational or transactional requests made by the Attorney(s)-in-Fact will be reviewed afternotification of acceptance.

Powers:

hen accepted, this POA may give your designated Attorney(s)-in-Fact the authority to (among other actions)• make inquiries and conduct transactions on your benefits with the same authority that you have• manage and initiate distributions of your benefits and• if so authorized, update your plan beneficiaries.Duration:

hen accepted, the authority you designate to the Attorney(s)-in-Fact will generally remain in effect until your death, even if you become incapacitated, unless you revoke the designation or a court appointed guardian or conservator terminates the designation. Upon notice of your death, Fidelity will terminate the authority given to your designated Attorney(s)-in-Fact. You may amend or change your POA designations by executing and submitting a new Durable Power of Attorney Form for review and acceptance. You have the right to revoke or terminate your POA designations at any time, by submitting a letter of revocation or termination to Fidelity which contains your notarized signature.








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of 15

Name

Mailing Address

City State ZIP Code

Social Security or Taxpayer ID Number D.O.B.

2. Plan Information

Plan Number Plan Number Plan Number Plan Number

Plan Name

Plan Name

Plan Name

Plan Name

I consent to establish access to all my employer plans and benefits administered by Fidelity for the employer noted below.

Employer Name

Form continues on next page.

Durable Power of Attorneyis e owe o tto ne o e se to est is n Attorney(s)-in-Fact o o

wo ce s in s n s ension n s n e t n we e n s ns w ic e eco e t i e it o ce e ices i e it T P A or o o

o I R r A o s IRA or r o o

1. Participant

Page 1 of 15

Name

Mailing Address

City State ZIP Code

Social Security or Taxpayer ID Number D.O.B.

2. Plan Information

Plan Number Plan Number Plan Number Plan Number

Plan Name

Plan Name

Plan Name

Plan Name

I consent to establish access to all my employer plans and benefits administered by Fidelity for the employer noted below.

Employer Name


Durable Power of Attorneyis e owe o tto ne o e se to est is n Attorney(s)-in-Fact o o

wo ce s in s n s ension n s n e t n we e n s ns w ic e eco e t i e it o ce e ices i e it T P A or o o

o I R r A o s IRA or r o o

1. Participant

This D urable Power of Attorney Form ( " POA" ) , may be used to establish an Attorney( s) -in-Fact for your workplace savings plan( s) , pension plan( s) , and health and welfare plan( s) ( " Plans" ) which are recordkept by Fidelity W orkplace S ervices, L L C ( " Fidelity" ) . This POA form does not apply to Fidelity Individual Retirement Accounts "IRA" or personal investment accounts.

3. Powers to be Granted

• Review this section thoroughly before choosing the access you want to grant your Attorney(s)-in-Fact. You are not authorized to grant your Attorney(s)-in-Fact greater authority than you currently have under your plan(s).

• Please check either Option A, Option B, or Option C below. Please check only one option.• By selecting Option C, you are granting all of the powers listed below to the Attorney(s)-in-Fact.

Option AInformational Access

Option BFull Access

1. Obtain information regarding your accounts by contacting a Fidelity phone representative ✓2. Request account statements and balance information ✓3. Request a status update on a distribution or outstanding check ✓ ✓4.

Request a stop payment and/or reissue of a check/disbursement

✓5.

Exchange funds within your Plan(s)

✓6.

Update the address of record on your Plan Account

✓7. Inquire about Plan beneficiary designations ✓8. Change Plan contributions allocations ✓9. Request or receive pension verifications ✓10. Obtain tax forms ✓11. Inquire and update about direct deposit/banking information ✓12.

Initiate distributions, rollovers, loans, and hardship withdrawals

13.

Make or change health and insurance benefits enrollments

14.

Receive account verification for Medicaid or general income verification

✓

15.

Request confirmation statement of insurance benefits

✓

16.

Request a status on a life insurance claim ✓

17. Change delivery method for statements

18. Update banking information on file

19. Make or change your beneficiary designations.

Required Check only one.

Option A. Information Access

Option B. Full Access

Option C. Transactional Access


Page 2 of 15

Option C Transactional Access

✓✓✓✓✓✓

✓✓✓✓✓✓

✓✓✓

✓

✓

✓✓

✓

✓✓✓

P No r o o C o r A or (s) will have fulltransactional authority and will have the ability to designate beneficiaries or change existing beneficiary designationsin accordance with the terms of the plan.

✓✓

What Your Attorney( )-in-Fact Can Do

First Name Middle Name Last Name

Social Security or Taxpayer ID Number Date of Birth MM DD YYYY Cell Phone

Street Address

City State ZIP Code

Relationship to Participant

Citizenship

U.S. citizen

Foreign citizen Information in this box must be completed.

Permanent U.S. resident Non-permanent U.S. resident Nonresident of U.S.Country of Citizenship Country of Tax Residency Only applicable to nonresidents of the U.S.

City, State/Province, and Country of Birth

Passport

DHS Permanent Resident Card

Employment Authorization Document

Foreign National Identity Document

Enter full name as it appears on any

government-issued, unexpired document (e.g.,

driver’s license, passport, permanent resident card).

Indicate your citizenship status.

Check one and attach a copy of a valid and

unexpired government ID showing number and photo.

Page 3 of 15


Must act jointly

Must act separately

4. Attorney(s)-in-Fact

Section 4 must be completed by the Attorney(s)-in-Fact. In this Section 4, “You” and “your” refer to the Attorney(s)-in-Fact.

Multiple Attorney( )-in-Fact

Note: If you are granting authority to more than one Attorney(s)-in-Fact, please submit a separate agent page for each Attorney(s)-in-Fact, and indicate your intent for multiple Attorney(s)-in-Fact to act jointly or separately on your behalf by checking the applicable box below.

5. Participant Signature and Datewit in

s o ecei t i e it in t e esence o not ic

• Acknowledge that Fidelity has not offered you any tax or legal advice (including advice as to whether this form satisfies the lawsof your state), and affirm that you have consulted with your attorney and/or tax advisor prior to executing this form about any aspects of this form that you did not understand.

• Understand that Fidelity is not responsible for any losses that you incur (meaning claims, damages, actions, demands, investment losses, or other losses, as well as any costs, charges, attorneys’ fees or other fees and expenses) as a result of any actions, or failures to act, on the part of your Attorney(s)-in-Fact.

• Agree to indemnify and hold Fidelity harmless from, and to pay Fidelity promptly upon demand for, any and all losses or financial obligations that may arise from the acts or omissions of your Attorney(s)-in-Fact with respect to your Plan account(s) and/or benefits, even after this agreement is terminated.

• Understand that this POA and indemnityis effective immediately and shall not be affected by your subsequent disability, or by any lapse of time. This POA revokes all previous POAs signed by you specifically relating to your account(s) and benefits in the Plans.

• Understand that Fidelity has accepted no lity for selecting, investigating,r

or mesponsibi

onitoring the activities of your Attorney-(s)in-Fact in connection with your Plan account(s) or benefits. Fidelity’s performance of services under this Durable Power of Attorney Form is not an endorsement of your Attorney(s)-in-Fact identified in Section 4.

• Understand that this POA is in addition to, and in no way restricts, any rights that may exist at law or under any other agreement(s) between you, your Attorney(s)-in-Fact, your Employer, and Fidelity.

• Understand that this POA will remain in effect until you give Fidelity appropriate notice of its revocation or change. You may do so by notifying Fidelity through a signed notarized letter, completing the Remove Existing Attorney(s)-in-Fact section of this form or by submitting a new form, which will override any previous forms on file. Any revocations or changes that you make will become effective only after Fidelity has a reasonable period of time to act. You will be responsible for your Attorney(s)-in-Fact’s actions, until Fidelity is ableto accommodate your requested revocation or change. Fidelity’s receipt of a certified copy of your death certificate will serve as evidence that any authority granted to your Attorney(s)-in-Fact has terminated by operation of law. However, Fidelity’s receipt of notice of revocation or termination shall in no way affect the validity of this POA as to your liability (revocation) or your Attorney(s)-in-Fact liability (revocation or death) under the indemnity herein contained, with reference to any transaction initiated by your Attorney(s)-in-Fact, prior to the actual receipt by Fidelity of notice of such revocation or termination.

• Understand that this POA and indemnification in it shall be construed, administered, and enforced according to the laws of the Commonwealth of Massachusetts, except as superseded by federal laws or regulationst shall inure to the benefit of the Plan and Fidelity and of any successor firm or firms and to the benefit of the affiliates and assigns of Fidelity or any successor firm shall be binding upon your successors, assignees, heirs, executors, and administrators, unless terminated as described above.

Participant Signature and Date continues on next page.

Page 4 of 15

• Affirm that you have selected yourAttorney(s)-in-Fact at your own risk. Agreethat this form is in addition to (and in noway limits or restricts) any and all rightswhich Fidelity may have under any otheragreement or agreements between Fidelityand the plan, and shall inure and continue infavor of Fidelity, its successors (by merger,consolidation, or otherwise) and assigns.

• Affirm that you have read, and that youunderstand and agree to be boundby, the provisions of this POA and anyapplicable state notices.

• Understand that all transactions will be executed in accordance with the terms and conditions of the agreements governing your Plan account(s) and benefits, including without limitation any plan documents, trust agreements, individual custodial account agreements, group custodial account agreements, recordkeeping agreements,and/or service agreements.

• Affirm that you appoint the individual(s) identified in Section 4 as your Attorney(s)-in-Fact, granting all powers identified in Section3 with respect to all plans identified in Section 2.

•

• Health Information Access Request. To the extent that Fidelity is a Business Associate to any and all health plans in which I am enrolled (“HealthAccount”), I request that Fidelity and its subcontractors provide to my Attorney-in-Fact upon his/her request, an electronic copy of my account information in its Designated Record Set (past, present and future) pursuant to the individual rights afforded me by HIPAA, 45 C.F.R. §164.524, which may include personal and health information for me and my minor and adult dependents’ for whom I have financial responsibility, including Protected Health Information as defined by HIPAA, claim, billing, payment, balance, benefit, enrollment or any other related health information maintained by my Health Account (collectively “Information ”).

• Acknowledgment . I acknowledge that any Information received by my Attorney-in-Fact is not Protected Health Information as defined by HIPAA and may not be protected by federal law.

• Term/Revocation. I understand that this Access Request shall remain in force and effect and will not expire until I revoke it by terminating this POA in writing .I understand that a request to revoke this Access Request is only effective after it is received, logged by Fidelity, and communicated to and processed by my Health Accounts, and that no disclosure made prior to its revocation will be affected.

5. Participant Signature and Date Participant must sign n te t is section in t e esence o not


• Understand that Fidelity is not responsible for any losses that you incur (meaning claims, damages, actions, demands, investment losses, or other losses, as well as any costs, charges, attorneys’ fees or other fees and expenses) as a result of any actions, or failures to act, on the part of your Attorney-in-Fact.

• Agree to indemnify and hold Fidelity harmless from, and to pay Fidelity promptly upon demand for, any and all losses or financial obligations that may arise from the acts or omissions of your Attorney-in-Fact with respect to your Plan account(s) and/or benefits, even after this agreement is terminated.


• Understand that Fidelity has accepted no responsibility for selecting, investigating,or monitoring the activities of your Attorney-in-Fact in connection with your Plan account(s) or benefits. Fidelity’s performance of services under this Durable Power of Attorney Form is not an endorsement of your Attorney-in-Fact identified in Section 4.

• Understand that this POA is in addition to, and in no way restricts, any rights that may exist at law or under any other agreement(s) between you, your Attorney-in-Fact, your Employer, and Fidelity.

• Understand that this POA will remain in effect until you give Fidelity appropriate notice of its revocation or change. You may do so by notifying Fidelity through a signed notarized letter, completing the Remove Existing Attorney-in-Fact section of this form or by submitting a new form, which will override any previous forms on file. Any revocations or changes that you make will become effective only after Fidelity has a reasonable period of time to act. You will be responsible for your Attorney-in-Fact’s actions, until Fidelity is able to accommodate your requested revocation or change. Fidelity’s receipt of a certified copy of your death certificate will serve as evidence that any authority granted to your Attorney(s)-in-Fact has terminated by operation of law. However, Fidelity’s receipt of notice of revocation or termination shall in no way affect the validity of this POA as to your liability (revocation) or your Attorney(s)-in-Fact liability (revocation or death) under the indemnity herein contained, with reference to any transaction initiated by your Attorney-in-Fact, prior to the actual receipt by Fidelity of notice of such revocation or termination.



Page 4 of 15


• Affirm that you have read, and that youunderstand and agree to be boundby, the provisions of this POA and anyapplicable state notices new section.


• Affirm that you appoint the individual(s)identified in Section 4 as your Attorney-in-Fact, granting all powers identified in Section3 with respect to all s identified inSection 2.

• If you have appointed two or more Attorney-in-Fact, and you authorize each of themto act alone (separately) and without theconsent of any other Attorney-in-Fact,with respect to each power granted withinthis Durable Power of Attorney Form, youacknowledge that Fidelity has the right torestrict your account(s) and/or benefits fromfurther activity in the event your Attorney-in-Fact enter conflicting or inconsistentinstructions. You understand that youraccount(s) and/or benefits may remainrestricted until instructions are received fromyou, the participant, or until joint writteninstructions are submitted by all of youragents, or until receipt of a court orderinstructing Fidelity how to proceed.














Page 4 of 15









• Health Information Access Request. To theextent that Fidelity is a Business Associate to any and all health plans in which I am enrolled (“Health Account”), I request that Fidelity and its subcontractors provide tomy Attorney(s)-in-Fact upon his/her request, an electronic copy of my account informationin its Designated Record Set (past, present and future) pursuant to the individual rights afforded me by HIPAA, 45 C.F.R. §164.524, which may include personal and health information for me and my minor and adult dependents’ for whom I have financial responsibility, including Protected Health Information as defined by HIPAA, claim, billing, payment, balance, benefit, enrollment or any other related health information maintained by my Health Account (collectively “Information”).

• Acknowledgment. I acknowledge that any Information received by my Attorney(s)-in-Fact is not Protected Health Information as defined by HIPAA and may not be protected by federal law.

• I understand that a request to revoke thisAccess Request is only effective after it isreceived, logged by Fidelity, and commu-

• Term/Revocation. I understand that this AccessRequest shall remain in force and effect and will not expire until I revoke it by terminating this POA in writing.

Understand that you have appointed two or more Attorney(s)-in-Fact, and you authorize each of them to act alone (separately) and without the consent of any other Attorney-in-Fact, with respect to each power granted within this Durable Power of Attorney Form, you acknowledge that Fidelity has the right to restrict your account(s) and/or benefits from further activity in the event your Attorney(s)-in-Fact enter conflicting or inconsistent instructions. You understand that your account(s) and/or benefits may remain restricted until instructions are received from you, the participant, or until joint written instructions are submitted by all of your agents, or until receipt of a court order instructing Fidelity how to proceed.

e tto ne s in ct st si n n te t is section5. Participant Signature and Datewit in

s o ecei t i e it in t e esence o not ic


• Understand that Fidelity is not responsible for any losses that you incur (meaning claims, damages, actions, demands, investment losses, or other losses, as well as any costs, charges, attorneys’ fees or other fees and expenses) as a result of any actions, or failures to act, on the part of your Attorney(s)-in-Fact.

• Agree to indemnify and hold Fidelity harmless from, and to pay Fidelity promptly upon demand for, any and all losses or financial obligations that may arise from the acts or omissions of your Attorney(s)-in-Fact with respect to your Plan account(s) and/or benefits, even after this agreement is terminated.


• Understand that Fidelity has accepted no lity for selecting, investigating,r

or mesponsibi

onitoring the activities of your Attorney-(s)in-Fact in connection with your Plan account(s) or benefits. Fidelity’s performance of services under this Durable Power of Attorney Form is not an endorsement of your Attorney(s)-in-Fact identified in Section 4.

• Understand that this POA is in addition to, and in no way restricts, any rights that may exist at law or under any other agreement(s) between you, your Attorney(s)-in-Fact, your Employer, and Fidelity.

• Understand that this POA will remain in effect until you give Fidelity appropriate notice of its revocation or change. You may do so by notifying Fidelity through a signed notarized letter, completing the Remove Existing Attorney(s)-in-Fact section of this form or by submitting a new form, which will override any previous forms on file. Any revocations or changes that you make will become effective only after Fidelity has a reasonable period of time to act. You will be responsible for your Attorney(s)-in-Fact’s actions, until Fidelity is ableto accommodate your requested revocation or change. Fidelity’s receipt of a certified copy of your death certificate will serve as evidence that any authority granted to your Attorney(s)-in-Fact has terminated by operation of law. However, Fidelity’s receipt of notice of revocation or termination shall in no way affect the validity of this POA as to your liability (revocation) or your Attorney(s)-in-Fact liability (revocation or death) under the indemnity herein contained, with reference to any transaction initiated by your Attorney(s)-in-Fact, prior to the actual receipt by Fidelity of notice of such revocation or termination.



Page 4 of 15


• Affirm that you have read, and that youunderstand and agree to be boundby, the provisions of this POA and anyapplicable state notices.


• Affirm that you appoint the individual(s) identified in Section 4 as your Attorney(s)-in-Fact, granting all powers identified in Section3 with respect to all plans identified in Section 2.

•














Page 4 of 15








• Term/Revocation. I understand that this Access Request shall remain in force ad effect and will not expire until I revoke it by terminating this POA in writing .I understand that a request to revoke this Access Request is only effective after it is received, logged by Fidelity, and communicated to and processed by my Health Accounts, and that no disclosure made prior to its revocation will be affected.











Page 4 of 15








• Term/Revocation. I understand that this Access Request shall remain in force and effect and will not expire until I revoke it by terminating this POA in writing .I understand that a request to revoke this Access Request is only effective after it is received, logged by Fidelity, and communicated to and processed by my Health Accounts, and that no disclosure made prior to its revotion will be affected.

• Health Information Access Request. To theextent that Fidelity is a Business Associate to any and all health plans in which I am enrolled (“Health Account”), I request that Fidelity and its subcontractors provide tomy Attorney(s)-in-Fact upon his/her request, an electronic copy of my account informationin its Designated Record Set (past, present and future) pursuant to the individual rights afforded me by HIPAA, 45 C.F.R. §164.524, which may include personal and health information for me and my minor and adult dependents’ for whom I have financial responsibility, including Protected Health Information as defined by HIPAA, claim, billing, payment, balance, benefit, enrollment or any other related health information maintained by my Health Account (collectively “Information”).

• Acknowledgment. I acknowledge that any Information received by my Attorney(s)-in-Fact is not Protected Health Information as defined by HIPAA and may not be protected by federal law.

• I understand that a request to revoke thisAccess Request is only effective after it isreceived, logged by Fidelity, and commu-

• Term/Revocation. I understand that this AccessRequest shall remain in force and effect and will not expire until I revoke it by terminating this POA in writing.

Understand that you have appointed two or more Attorney(s)-in-Fact, and you authorize each of them to act alone (separately) and without the consent of any other Attorney-in-Fact, with respect to each power granted within this Durable Power of Attorney Form, you acknowledge that Fidelity has the right to restrict your account(s) and/or benefits from further activity in the event your Attorney(s)-in-Fact enter conflicting or inconsistent instructions. You understand that your account(s) and/or benefits may remain restricted until instructions are received from you, the participant, or until joint written instructions are submitted by all of your agents, or until receipt of a court order instructing Fidelity how to proceed.

e tto ne s in ct st si n n te t is section

• Affirm that you have selected your Attorney( s) -in-Fact at your own risk. Agree that this form is in addition to ( and in no way limits or restricts) any and all rights which Fidelity may have under any other agreement or agreements between Fidelity and the plan, and shall inure and continue in favor of Fidelity, its successors ( by merger, consolidation, or otherwise) and assigns.

• Affirm that you have read, and that you understand and agree to be bound by, the provisions of this POA and any applicable state notices.

• U nderstand that all transactions will be executed in accordance with the terms and conditions of the agreements governing your Plan account(s) and benefits, including without limitation any plan documents, trust agreements, individual custodial account agreements, group custodial account agreements, recordkeeping agreements, and/or service agreements.

• Affirm that you appoint the individual(s) identified in Section 4 as your Attorney(s)-in-Fact, granting all powers identified in Section 3 with respect to all plans identified in S ection 2 .

• U nderstand that, if you have appointed two or more Attorney( s) -in-Fact, and you authoriz e each of them to act alone ( separately) and without the consent of any other Attorney( s) -in-Fact, with respect to each power granted within this D urable Power of Attorney Form, you acknowledge that Fidelity has the right to restrict your account( s) and/or benefits from further activity in the event your Attorney(s)-in-Fact enter conflicting or inconsistent instructions. Y ou understand that your account(s) and/or benefits may remain restricted until instructions are received from you, the participant, or until j oint written instructions are submitted by all of your agents, or until receipt of a court order instructing Fidelity how to proceed.

• Acknowledge that Fidelity has not offered you any tax or legal advice ( including advice as to whether this form satisfies the laws of your state), and affirm that you have consulted with your attorney and/or tax advisor prior to executing this form about any aspects of this form that you did not understand.

• U nderstand that Fidelity is not responsible for any losses that you incur ( meaning claims, damages, actions, demands, investment losses, or other losses, as well as any costs, charges, attorneys’ fees or other fees and expenses) as a result of any actions, or failures to act, on the part of your Attorney( s) -in-Fact.

• Agree to indemnify and hold Fidelity harmless from, and to pay Fidelity promptly upon demand for, any and all losses or financial obligations that may arise from the acts or omissions of your Attorney( s) -in-Fact

with respect to your Plan account( s) and/or benefits, even after this agreement is terminated.

• U nderstand that this POA and indemnity is effective immediately and shall not be affected by your subsequent disability, or by any lapse of time. This POA revokes all previous POAs signed by you specifically relating to your account(s) and benefits in the Plans.

• U nderstand that Fidelity has accepted no responsibility for selecting, investigating, or monitoring the activities of your Attorney( s) -in-Fact in connection with your Plan account(s) or benefits. Fidelity’s performance of services under this D urable Power of Attorney Form is not an endorsement of your Attorney( s) -in-Fact identified in Section 4.

• U nderstand that this POA is in addition to, and in no way restricts, any rights that may exist at law or under any other agreement( s) between you, your Attorney( s) -in-Fact, your E mployer, and Fidelity.

• U nderstand that this POA will remain in effect until you give Fidelity appropriate notice of its revocation or change. Y ou may do so by notifying Fidelity through a signed notariz ed letter, completing the Remove E xisting Attorney( s) -in-Fact section of this form or by submitting a new form, which will override any previous forms on file. Any revocations or changes that you make will become effective only after Fidelity has a reasonable period of time to act. Y ou will be responsible for your Attorney( s) -in-Fact’ s actions, until Fidelity is able to accommodate your requested revocation or change. Fidelity’s receipt of a certified copy of your death certificate will serve as evidence that any authority granted to your Attorney( s) -in-Fact has terminated by operation of law. However, Fidelity’ s receipt of notice of revocation or termination shall in no way affect the validity of this POA as to your liability ( revocation) or your Attorney( s) -in-Fact liability ( revocation or death) under the indemnity herein contained, with reference to any transaction initiated by your Attorney( s) -in-Fact, prior to the actual receipt by Fidelity of notice of such revocation or termination.

• U nderstand that this POA and indemnification in it shall be construed, administered, and enforced according to the laws of the C ommonwealth of M assachusetts, except as superseded by federal laws or regulations shall inure to the benefit of the Plan and Fidelity and of any successor firm or firms and to the benefit of the affiliates and assigns of Fidelity or any successor firm shall be binding upon your successors, assignees, heirs, executors, and administrators unless terminated as described above.

Health Information: • Health Information Access Request. To the

extent that Fidelity is a B usiness Associate to any and all health plans in which I am enrolled ( “ Health Account” ) , I request that Fidelity and its subcontractors provide to my Attorney( s) -in-Fact upon his/her request, an electronic copy of my account information in its D esignated Record S et ( past, present and future) pursuant to the individual rights afforded me by HIPAA, 45 C.F.R. §164.524, which may include personal and health information for me and my minor and adult dependents’ for whom I have financial responsibility, including Protected Health Information as defined by HIPAA, claim, billing, payment, balance, benefit, enrollment or any other related health information maintained by my Health Account ( collectively “ Information ” ) .

• Acknowledgment. I acknowledge that any Information received by my Attorney( s) -in-Fact is not Protected Health Information as defined by HIPAA and may not be protected by federal law.

• I understand that a request to revoke this Access Request is only effective after it is received, logged by Fidelity, and communicated to and processed by my Health Accounts, and that no disclosure made prior to its revocation will be affected.

• Term/Revocation. I understand that this Access Request shall remain in force and effect and will not expire until I revoke it by terminating this POA in writing.

Participant Signature and Date, continued

You must sign and date this form in the presence of two witnesses and a notary public.

I have read and understand the important information in this Durable Power of Attorney Form. I acknowledge Fidelity’s role. I understand

that a notary public must witness my signature. The notary public may not be the Attorney-in- Fact, an immediate family member of the Attorney-in-Fact, or an immediate member of my family.

PRINT PARTICIPANT’S NAME

PARTICIPANT’S SIGNATURE DATE MM/DD/YYYY

SIG

N X XPRINT WITNESS NAME

WITNESS SIGNATURE DATE MM/DD/YYYY

SIG



SIG

N X X

Page 5 of 15





SIG



SIG



SIG

N X

X

Certificate of Acknowledgment of Notary Public Must be a U.S. Notary. Foreign notary or consular seals may NOT be substituted.

State of , in the County of , subscribed and sworn to before me by the

above-named individual who is personally known to me or who has produced as identification, that the

foregoing statements were true and accurate and made of his/her own free act and deed, on / / .

PRINT NOTARY NAME NOTARY SEAL / STAMP

NOTARY SIGNATURE DATE MM/DD/YYYY

SIG

N X XMy commission expires / / .

Page 5 of 15

Overnight mailAttention: Qualification Services.

100 Crosby Parkway, KC1FCovington, KY 41015

Regular mailFidelity Investments

P.O. Box 770003 Cincinnati, OH 45277-0065

Did you sign the form and attach any necessary documents? Send the ENTIRE form and any attachments to Fidelity Investments

.

s s



I have read and understand the important information in this Durable Power of Attorney Form. I acknowledge Fidelity’s role. I understand that a notary public must witness my signature. The notary public may not be the Attorney-in- Fact, an immediate family member of the

Attorney-in-Fact, or an immediate member of my family.



SIG



SIG



SIG

N X X







SIG


Page 5 of 15






.

s s

6. Attorney-in-Fact Signature and Date, continued

of 15

I have read and understand the important information in this Durable Power of Attorney form. I acknowledge the Plan and Fidelity’s role and accept the conditions described above. I understand that a notary public must witness my signature. The notary public may not be the Attorney-in-Fact or an immediate family member of the Attorney-in-Fact.

PRINT ATTORNEY-IN-FACT’S NAME

ATTORNEY-IN-FACT’S SIGNATURE DATE MM/DD/YYYY

SIG

N X X

Important Note: CA Notaries are permitted to submit a separate page notary document. If used, it must identify thedocument being notarized.

Must be a U.S. Notary. Foreign notary or consular seals may NOT be substituted.






SIG


Certificate Certificate of Acknowledgment of Notary of Acknowledgment of Notary Public Public



SIG


Overnight mailAttention: Qualification Services.100 Crosby Parkway, KC1F Covington, KY 41015

Regular mailFidelity Investments P.O. Box 770003 Cincinnati, OH 45277-0065

Did you sign the form and attach any necessary documents? Send the ENTIRE form and any attachments to Fidelity Investments.

s s

Notice to CA Residents: A Notary Public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validthat document.

s s s s s



I have read and understand the important information in this Durable Power of Attorney Form. I acknowledge Fidelity’s role. I understand

that a notary public must witness my signature. The notary public may not be the Attorney-in- Fact, an immediate family member of the Attorney-in-Fact, or an immediate member of my family.



SIG



SIG



SIG

N X X

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SIG



SIG

N X

X







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.

s s



I have read and understand the important information in this Durable Power of Attorney Form. I acknowledge Fidelity’s role. I understand that a notary public must witness my signature. The notary public may not be the Attorney-in- Fact, an immediate family member of the

Attorney-in-Fact, or an immediate member of my family.



SIG



SIG



SIG

N X X







SIG


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.

s s


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SIG

N X X

Important Note: CA Notaries are permitted to submit a separate page notary document. If used, it must identify thedocument being notarized.







SIG





SIG





s s


s s s s s

I have read and understand the important information in this Durable Power of Attorney form. I acknowledge the Plan and Fidelity’s role and accept the conditions described above. I understand that a notary public must witness my signature. The notary public may not be the Attorney(s)-in-Fact or an immediate family member of the Attorney(s)-in-Fact.

section within 90 days of receipt by Fidelity in the presence of a notary public.

By signing below, you: • Affirm that you have read, and that you

understand and agree to be bound by,the provisions of this form as well as,with the terms and conditions of theagreements governing the Plan account(s)and benefits, including without limitation anyplan documents, trust agreements, individualcustodial account agreements, groupcustodial account agreements, recordkeepingagreements, and/or service agreements, aswell as any applicablestate notices.

• Affirm that you are the Attorney-in-Factnamed in Section 4.

• Accept appointment as Attorney-in-Factfor the participant identified in Section1, according to all terms and conditionsdescribed in this form.

• Affirm that the is not deceased,has not partially or totally revoked,suspended, or terminated the authoritydelegated and that there is no petitionpending to determine the incapacity of or toappoint a guardian for the participant.

• Agree not to issue or relay any instructionsthat you believe to be inconsistent with yourpowers or responsibilities as Attorney-in-Fact.

• Agree to avoid conflicts that would impairyour ability to act in the participant’s bestinterest.

• Agree to keep the participant’s propertyseparate from any assets you own or control,unless otherwise permitted by law.

• Agree to keep a record of all receipts,payments, and transactions conductedfor the participant.

• Agree to identify yourself as Attorney-in-Factwhen signing documents on behalf of theparticipant, using either of these acceptedforms: “[participant’s name] by [yoursignature] as Attorney-in-Fact,” or “[your signature] as Attorney-in-Fact for[participant name]”.

• In the event that more than one Attorney-in-Fact is named, represent that you areauthorized to act severally or individually,and that Fidelity may follow any of yourinstructions independent of all otherAttorneys-in-Fact, including the deliveryof assets to you personally.

• Understand that in the event of anyconflict between instructions given byAttorneys-in-Fact or by participant and anAttorney-in-Fact, Fidelity may restrict thePlan account until it has received satisfactoryjoint written instructions.

• Indemnify and hold harmless Fidelity fromand against any and all losses, liabilities,claims, and costs (including reasonableattorneys’ fees) resulting from transactionsmade in accordance with your instructions.

• Agree that Fidelity may restrict or suspendyour ability to remove money from theaccounts listed in Section 2.

• Agree to serve as Attorney-in-Fact, and acknowledge that this POA remains in full force and effect.

• Agree to cease acting as Attorney-in-Fact if you know, or have reason to know, that yourcapacity to act as Attorney-in-Fact has been limited or terminated for any reason.

• Certify that you will not be paid for the investment management related to the account(s).

• Consent to your appointment as the Attorney-in-Fact identified in this form, understanding that:– As the Attorney-in-Fact, you will be

granted only the powers described in this form, and will be authorized only to take actions that are permitted by the Plans.

This Durable Power of Attorney Form shall be governed by Massachusetts law, except with respect to its conflict of laws provisions.

Attorney-in-Fact Signature and Date continues on next page.

Page 6 of 15

To help the government fight financial crimes, federal regulation requires Fidelity to obtain your name, date of birth, address, and a government-issued ID number to verify the information. In certain circumstances, Fidelity may obtain and verify comparable information for any person authorized to make transactions in an account. Also, federal regulation requires Fidelity to obtain and verify the beneficial owners and control persons of legal entity customers. Requiring the disclosure of key individuals who own or control a legal entity helps law enforcement investigate and prosecute crimes. Your account may be restricted or closed if Fidelity cannot obtain and verify this information. Fidelity will not be responsible for any losses or damages (including, but not limited to, lost opportunities) that may result if your account is restricted or closed.

6. Attorney(s)-in-Fact Signature and Date Named Attorney-in-Fact must sign and date this

In this Section, “You” and “your” refer to the Attorney(s)-in-Fact.

By signing below, you: •

understand and agree to be bound by, the provisions of this form as well as, with the terms and conditions of the agreements governing the Plan account(s)

splan documents, trust agreements, individual custodial account agreements, group custodial account agreements, recordkeeping agreements, and/or service agreements, as well as any applicable state notices.

(s)named in Section 4.

• Accept appointment as Attorney(s)-in-Fact

1, according to all terms and conditions described in this form.

• s s has not partially or totally revoked, suspended, or terminated the authority delegated and that there is no petition pending to determine the incapacity of or to appoint a guardian for the participant.

• Agree not to issue or relay any instructions that you believe to be inconsistent with your powers or responsibilities as Attorney(s)-in-Fact.

syour ability to act in the participant’s best interest.

• Agree to keep the participant’s property separate from any assets you own or control, unless otherwise permitted by law.

• Agree to keep a record of all receipts, payments, and transactions conducted for the participant.

• Agree to identify yourself as Attorney(s)-in-Fact when signing documents on behalf of the participant, using either of these accepted forms: “[participant’s name] by [your signature] as Attorney(s)-in-Fact,” or “ [your signature] as Attorney(s)-in-Fact for [participant name]”.

• In the event that more than one Attorney(s)-in-Fact is named, represent that you are authorized to act severally or individually, and that Fidelity may follow any of your instructions independent of all other Attorneys-in-Fact, including the delivery of assets to you personally.

• Understand that in the event of any s s

Attorneys-in-Fact or by participant and an Attorney(s)-in-Fact, Fidelity may restrict the Plan account until it has received satisfactory joint written instructions.

• Indemnify and hold harmless Fidelity from and against any and all losses, liabilities, claims, and costs (including reasonable attorneys’ fees) resulting from transactions made in accordance with your instructions.

• Agree that Fidelity may restrict or suspend your ability to remove money from the accounts listed in Section 2.

• Agree to serve as Attorney(s)-in-Fact, and acknowledge that this POA remains in full force and effect.

• Agree to cease acting as Attorney(s)-in-Fact if you know, or have reason to know, that your capacity to act as Attorney(s)-in-Fact has been limited or terminated for any reason.


• Consent to your appointment as the (s) s

understanding that:– As the Attorney(s)-in-Fact, you will be


section within 90 days of receipt by Fidelity in the presence of a notary public.

By signing below, you: • Affirm that you have read, and that you

understand and agree to be bound by,the provisions of this form as well as,with the terms and conditions of theagreements governing the Plan account(s)and benefits, including without limitation anyplan documents, trust agreements, individualcustodial account agreements, groupcustodial account agreements, recordkeepingagreements, and/or service agreements, aswell as any applicablestate notices.

• Affirm that you are the Attorney-in-Factnamed in Section 4.

• Accept appointment as Attorney-in-Factfor the participant identified in Section1, according to all terms and conditionsdescribed in this form.

• Affirm that the is not deceased,has not partially or totally revoked,suspended, or terminated the authoritydelegated and that there is no petitionpending to determine the incapacity of or toappoint a guardian for the participant.

• Agree not to issue or relay any instructionsthat you believe to be inconsistent with yourpowers or responsibilities as Attorney-in-Fact.

• Agree to avoid conflicts that would impairyour ability to act in the participant’s bestinterest.

• Agree to keep the participant’s propertyseparate from any assets you own or control,unless otherwise permitted by law.

• Agree to keep a record of all receipts,payments, and transactions conductedfor the participant.

• Agree to identify yourself as Attorney-in-Factwhen signing documents on behalf of theparticipant, using either of these acceptedforms: “[participant’s name] by [yoursignature] as Attorney-in-Fact,” or “[your signature] as Attorney-in-Fact for[participant name]”.

• In the event that more than one Attorney-in-Fact is named, represent that you areauthorized to act severally or individually,and that Fidelity may follow any of yourinstructions independent of all otherAttorneys-in-Fact, including the deliveryof assets to you personally.

• Understand that in the event of anyconflict between instructions given byAttorneys-in-Fact or by participant and anAttorney-in-Fact, Fidelity may restrict thePlan account until it has received satisfactoryjoint written instructions.

• Indemnify and hold harmless Fidelity fromand against any and all losses, liabilities,claims, and costs (including reasonableattorneys’ fees) resulting from transactionsmade in accordance with your instructions.

• Agree that Fidelity may restrict or suspendyour ability to remove money from theaccounts listed in Section 2.

• Agree to serve as Attorney-in-Fact, and acknowledge that this POA remains in full force and effect.

• Agree to cease acting as Attorney-in-Fact if you know, or have reason to know, that yourcapacity to act as Attorney-in-Fact has been limited or terminated for any reason.


• Consent to your appointment as the Attorney-in-Fact identified in this form, understanding that:– As the Attorney-in-Fact, you will be


This Durable Power of Attorney Form shall be governed by Massachusetts law, except with respect to its conflict of laws provisions.

Attorney-in-Fact Signature and Date continues on next page.

Page 6 of 15

To help the government fight financial crimes, federal regulation requires Fidelity to obtain your name, date of birth, address, and a government-issued ID number to verify the information. In certain circumstances, Fidelity may obtain and verify comparable information for any person authorized to make transactions in an account. Also, federal regulation requires Fidelity to obtain and verify the beneficial owners and control persons of legal entity customers. Requiring the disclosure of key individuals who own or control a legal entity helps law enforcement investigate and prosecute crimes. Your account may be restricted or closed if Fidelity cannot obtain and verify this information. Fidelity will not be responsible for any losses or damages (including, but not limited to, lost opportunities) that may result if your account is restricted or closed.

6. Attorney(s)-in-Fact Signature and Date Named Attorney-in-Fact must sign and date this

In this Section, “You” and “your” refer to the Attorney(s)-in-Fact.

6. Attorney s -in-Fact Signature and Date, continued

Page 7 of 15

PRINT ATTORNEY(S)-IN-FACT’S NAME

ATTORNEY(S)-IN-FACT’S SIGNATURE DATE MM/DD/YYYY

SIG

N X XImportant Note: CA Notaries are permitted to submit a separate page notary document. If used, it must identify the document being notarized.

Notice to CA Residents: A Notary Public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document.







SIG



Page 7 of 15



SIG









SIG



Page 7 of 15



SIG









SIG




I have read and understand the important information in this Durable Power of Attorney Form. I acknowledge Fidelity’s role. I understand that a notary public must witness my signature. The notary public may not be the Attorney-in- Fact, an immediate family member of the Attorney-in-Fact, or an immediate member of my family.



SIG



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N X X

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X







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Overnight mailAttention: Qualification Services.100 Crosby Parkway, KC1FCovington, KY 41015



s s






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s s


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SIG

N X XImportant Note: CA Notaries are permitted to submit a separate page notary document. If used, it must identify thedocument being notarized.







SIG





SIG





s s


This Durable Power of Attorney Form shall be governed by Massachusetts law, except with respect to its conflict of laws provisions. To help the government fight financial crimes, federal regulation requires Fidelity to obtain your name, date of birth, address, and a government-issued ID number to verify the information. In certain circumstances, Fidelity may obtain and verify comparable information for any person authorized to make transactions in an account. Also, federal regulation requires Fidelity to obtain and verify the beneficial owners and control persons of legal entity customers. Requiring the disclosure of key individuals who own or control a legal entity helps law enforcement investigate and prosecute crimes. Your account may be restricted or closed if Fidelity cannot obtain and verify this information. Fidelity will not be responsible for any losses or damages (including, but not limited to, lost opportunities) that may result if your account is restricted or closed.

s s s s s



Questions? Call 800-835-5097.


Overnight mailAttention: Qualification 100 Crosby Parkway, KC1FCovington, KY 41015

Remove Existing Attorneys-in-Fact

Complete this section ONLY if you want to remove one or more existing Attorney(s)-in-Fact from your account(s).

Name of Attomey(s)-in-Fact







SIG


Page 8 of 15

I have read and understand the important information in this Durable Power of Attorney form. I acknowledge the Plan and Fidelity’s role and accept the conditions described in Section 5. I understand that a notary public must witness my signature. The notary public may not be the Attorney-in-Fact, an immediate family member of the Attorney-in-Fact, or an immediate member of my family.


PRINT WITNESS NAME


SIG



SIG

N X X

PRINT PARTICIPANT'S NAME

PARTICIPANT'S SIGNATURE DATE MM/DD/YYYY

SIG

N X X







Name of Attomey-in-Fact







SIG


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PRINT WITNESS NAME


SIG



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N X X



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N X X












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PRINT WITNESS NAME


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N X X



SIG

N X X



Regular mail Fidelity Investments P.O. Box 770003 Cincinnati, OH 45277-0065

Overnight mail Attention: Qualification 100 Crosby Parkway, KC1FCovington, KY 41015










SIG


Page 8 of 15



PRINT WITNESS NAME


SIG



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N X X



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N X X














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Page 8 of 15


PRINT WITNESS NAME


SIG



SIG

N X X


SIG

N X X6. Attorney-in-Fact Signature and Date, continued

Page 7 of 15




SIG









SIG


Remove Existing Attorney(s)-in-Fact

Complete this section ONLY if you want to remove one or more existing Attorney(s)-in-Fact from your account.

(s)














SIG


Page 8 of 15



PRINT WITNESS NAME


SIG



SIG

N X X



SIG

N X X














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Page 8 of 15



PRINT WITNESS NAME


SIG



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N X X



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N X X












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PRINT WITNESS NAME


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N X X



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PRINT WITNESS NAME


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N X X



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N X X














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Page 8 of 15


PRINT WITNESS NAME


SIG



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(s)














SIG


Page 8 of 15



PRINT WITNESS NAME


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N X X



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PRINT WITNESS NAME


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N X X



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N X X












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Page 8 of 15



PRINT WITNESS NAME


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N X X



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N X X














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Page 8 of 15



PRINT WITNESS NAME


SIG



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N X X



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N X X














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Page 8 of 15


PRINT WITNESS NAME


SIG



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N X X


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(s)






SIG



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N X X

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X







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s s






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s s


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s s



s s s s s


PRINT PARTICIPANT'S NAME & SSN NUMBER REQUIRED

Notice for California Residents Pursuant to Cal. Prob. Code § 4128

Notice to Person Executing Durable Power of AttorneyThis notice must also be read and signed by the Attorney(s)-in-Fact.A durable power of attorney is an important legal document. By signing the durable power of attorney, you are authorizing another person to act for you, the principal. Before you sign this Durable Power of Attorney, you should know these important facts:Your agent Attorney-in-Fact has no duty to act unless you and your agent agree otherwise in writing.This document gives your agent the powers to manage, dispose of, sell, and convey your real and personal property, and to use your property as security if your agent borrows money on your behalf. This document does not give your agent the power to accept or receive any of your property, in trust or otherwise, as a gift, unless you specifically authorize the agent to accept or receive a gift.

Your agent will have the right to receive reasonable payment for services provided under this Durable Power of Attorney unless you provide otherwise in this power of attorney.The powers you give your agent will continue to exist for your entire lifetime, unless you state that the durable power of attorney will last for a shorter period of time or unless you otherwise terminate the durable power of attorney. The powers you give your agent in this Durable Power of Attorney will continue to exist even if you can no longer make your own decisions respecting the management of your property.You can amend or change this Durable Power of Attorney only by executing a new Durable Power of Attorney or by executing an amendment through the same formalities as an original.You have the right to revoke or terminate this Durable Power of Attorney at any time, so long as you are competent.

This Durable Power of Attorney must be dated and must be acknowledged before a notary public or signed by two witnesses. If it is signed by two witnesses, they must witness either: 1. The signing of the power of attorney.2. The principal’s signing or

acknowledgment of his or her signature.

Notice to Person Accepting the Appointment as Attorney-in-FactBy acting or agreeing to act as the agent (Attorney-in-Fact) under this power of attorney you assume the fiduciary and other legal responsibilities of an agent. These responsibilities include:1. The legal duty to act solely in the interest

of the principal and to avoid conflicts ofinterest.

2. The legal duty to keep the principal’sproperty separate and distinct from anyother property owned or controlled by you.

You may not transfer the principal’s property to yourself without full and adequate consideration or accept a gift of the principal’s property unless this power of attorney specifically authorizes you to transfer property to yourself or accept a gift of the principal’s property. If you transfer the principal’s property to yourself without specific authorization in the power of attorney, you may be prosecuted for fraud and/or embezzlement. If the principal is 65 years of age or older at the time that

A durable power of attorney that may affect real property should be acknowledged before a notary public so that it may easily be recorded.You should read this Durable Power of Attorney carefully. When effective, this durable power of attorney will give your agent the right to deal with property that you now have or might acquire in the future. The Durable Power of Attorney is important to you. If you do not understand the Durable Power of Attorney, or any provision of it, then you should obtain the assistance of an attorney or other qualified person.

the property is transferred to you without authority, you may also be prosecuted for elder abuse under Penal Code Section 368. In addition to criminal prosecution, you may also be sued in civil court.I have read the foregoing notice and I understand the legal and fiduciary duties that I assume by acting or agreeing to act as the agent (Attorney-in-Fact) under the terms of this power of attorney.

Page 9 of 15

Notice for California Residents continues on next page.

This notice must also be read and signed by the Attorney(s)-in-Fact.A durable power of attorney is an important legal document. By signing the durable power of attorney, you are authorizing another person to act for you, the principal. Before you sign this Durable Power of Attorney, you should know these important facts:Your agent Attorney(s)-in-Fact has no duty to act unless you and your agent agree otherwise in writing.This document gives your agent the powers to manage, dispose of, sell, and convey your real and personal property, and to use your property as security if your agent borrows money on your behalf. This document does not give your agent the power to accept or receive any of your property, in trust or otherwise, as a gift,

ss s to accept or receive a gift.



acknowledgment of his or her signature.A durable power of attorney that may affect real property should be acknowledged before a notary public so that it may easily be recorded.You should read this Durable Power of Attorney carefully. When effective, this durable power of attorney will give your agent the right to deal with property that you now have or might acquire in the future. The Durable Power of Attorney is important to you. If you do not understand the Durable Power of Attorney, or any provision of it, then you should obtain the assistance

s

the property is transferred to you without authority, you may also be prosecuted for elder abuse under Penal Code Section 368. In addition to criminal prosecution, you may also be sued in civil court.I have read the foregoing notice and I

s sthat I assume by acting or agreeing to act as the agent (Attorney(s)-in-Fact) under the terms of this power of attorney.

By acting or agreeing to act as the agent (Attorney(s)-in-Fact) under this power of

sslegal responsibilities of an agent. These responsibilities include:1. The legal duty to act solely in the interest

sinterest.

2. The legal duty to keep the principal’s property separate and distinct from any other property owned or controlled by you.

Notice to Person Accepting the Appointment as Attorney(s)-in-FactYou may not transfer the principal’s property to yourself without full and adequate consideration or accept a gift of the principal’s property unless this power

s stransfer property to yourself or accept a gift of the principal’s property. If you transfer the principal’s property to yourself without sattorney, you may be prosecuted for fraud and/or embezzlement. If the principal is 65 years of age or older at the time that

Notice for California Residents Pursuant to Cal. Prob. Code § 4128

Notice to Person Executing Durable Power of AttorneyThis notice must also be read and signed by the Attorney(s)-in-Fact.A durable power of attorney is an important legal document. By signing the durable power of attorney, you are authorizing another person to act for you, the principal. Before you sign this Durable Power of Attorney, you should know these important facts:Your agent Attorney-in-Fact has no duty to act unless you and your agent agree otherwise in writing.This document gives your agent the powers to manage, dispose of, sell, and convey your real and personal property, and to use your property as security if your agent borrows money on your behalf. This document does not give your agent the power to accept or receive any of your property, in trust or otherwise, as a gift, unless you specifically authorize the agent to accept or receive a gift.



acknowledgment of his or her signature.

Notice to Person Accepting the Appointment as Attorney-in-FactBy acting or agreeing to act as the agent (Attorney-in-Fact) under this power of attorney you assume the fiduciary and other legal responsibilities of an agent. These responsibilities include:1. The legal duty to act solely in the interest

of the principal and to avoid conflicts ofinterest.

2. The legal duty to keep the principal’sproperty separate and distinct from anyother property owned or controlled by you.

You may not transfer the principal’s property to yourself without full and adequate consideration or accept a gift of the principal’s property unless this power of attorney specifically authorizes you to transfer property to yourself or accept a gift of the principal’s property. If you transfer the principal’s property to yourself without specific authorization in the power of attorney, you may be prosecuted for fraud and/or embezzlement. If the principal is 65 years of age or older at the time that

A durable power of attorney that may affect real property should be acknowledged before a notary public so that it may easily be recorded.You should read this Durable Power of Attorney carefully. When effective, this durable power of attorney will give your agent the right to deal with property that you now have or might acquire in the future. The Durable Power of Attorney is important to you. If you do not understand the Durable Power of Attorney, or any provision of it, then you should obtain the assistance of an attorney or other qualified person.

the property is transferred to you without authority, you may also be prosecuted for elder abuse under Penal Code Section 368. In addition to criminal prosecution, you may also be sued in civil court.I have read the foregoing notice and I understand the legal and fiduciary duties that I assume by acting or agreeing to act as the agent (Attorney-in-Fact) under the terms of this power of attorney.

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I have read and understand the important information in this Durable Power of Attorney form. I acknowledge the Plan and Fidelity’s role and accept the conditions described above. I understand that a notary public must witness my signature. The notary public may not be the Attorney-in-Fact or an immediate family member of the Attorneys-in-Fact.


PARICIPANT’S SIGNATURE DATE MM/DD/YYYY

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Notice for Maine Residents Pursuant to 18-A M.R.S. § 5-905.

Important Notice to the Account OwnerAs the Account Owner, you are using this Power of Attorney to grant power to another person (called the Agent) to make decisions about your property and to use your property on your behalf. Under this Power of Attorney you give your Agent broad and sweeping powers to sell or other-wise dispose of your property without notice to you. Under this document your Agent will continue to have these powers after you become incapacitated. The powers that you give your Agent are explained more fully in the Maine Uniform Power of Attorney Act, Maine Revised Statutes, Title 18-A, Article 5, Part 9. You have the right to revoke this Power of Attorney at any time as long as you are not incapacitated. If there is any-thing about this Power of Attorney that you do not understand, you should ask a lawyer to explain it to you.

Important Notice to the AgentAs the “Agent” you are given power under this Power of Attorney to make decisions about the property belonging to the Principal and to dispose of the Principal’s property on the Principal’s behalf in accordance with the terms of this Power of Attorney. This Power of Attorney is valid only if the Principal is of sound mind when the Principal signs it. When you accept the authority granted under this power of attorney, a special legal relationship is created between you and the Principal. This relationship imposes upon you legal duties that continue until you resign or the Power of Attorney is terminated or revoked. The duties are more fully explained in the Maine Uniform Power of Attorney Act, Maine Revised Statutes, Title 18-A, Article 5, Part 9. As the Agent, you are generally not entitled to use the Principal’s property for your own benefit or to make gifts to yourself or others unless the power of attorney gives you such authority. If you violate your duty

under this Power of Attorney you may be liable for damages and may be subject to criminal prosecution.You must stop acting on behalf of the Principal if you learn of any event that terminates this Power of Attorney or your authority under this power of attor-ney. Events of termination are more fully explained in the Maine Uniform Power of Attorney Act and include, but are not lim-ited to, revocation of your authority or of the power of attorney by the Principal, the death of the Principal or the commence-ment of divorce proceedings between you and the Principal. If there is anything about this Power of Attorney or your duties under it that you do not understand, you should ask a lawyer to explain it to you.

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NOTICE FOR PENNSYLVANIA RESIDENTS PURSUANT TO 20 PA.C.S.A. § 5601.

NOTICE THIS NOTICE MUST BE SIGNED BY THE ACCOUNT OWNER.THE PURPOSE OF THIS POWER OF ATTORNEY IS TO GIVE THE PERSON YOU DESIGNATE (YOUR “AGENT”) BROAD POWERS TO HANDLE YOUR PROPERTY, WHICH MAY INCLUDE POWERS TO SELL OR OTHERWISE DISPOSE OF ANY REAL OR PERSONAL PROPERLY WITHOUT ADVANCE NOTICE TO YOU OR APPROVAL BY YOU.THIS POWER OF ATTORNEY DOES NOT IMPOSE A DUTY ON YOUR AGENT TO EXERCISE GRANTED POWERS, BUT, WHEN POWERS ARE EXERCISED, YOUR AGENT MOST USE DUE CARE TO ACT FOR YOUR BENEFIT AND IN ACCORDANCE WITH THIS POWER OF ATTORNEY.

YOUR AGENT MAY EXERCISE THE POW-ERS GIVEN HERE THROUGHOUT YOUR LIFETIME, EVEN AFTER YOU BECOME INCAPACITATED, UNLESS YOU EXPRESSLY LIMIT THE DURATION OF THESE POWERS OR YOU REVOKE THESE POWERS OR A COURT ACTING ON YOUR BEHALF TERMI-NATES YOUR AGENT’S AUTHORITY.YOUR AGENT MUST ACT IN ACCORDANCE WITH YOUR REASONABLE EXPECTATIONS TO THE EXTENT ACTUALLY KNOWN BY YOUR AGENT AND, OTHERWISE, IN YOUR BEST INTEREST, ACT IN GOOD FAITH AND ACT ONLY WITHIN THE SCOPE OF AUTHORITY GRANTED BY YOU IN THE POWER OF ATTORNEY. THE LAW PERMITS YOU, IF YOU CHOOSE, TO GRANT BROAD AUTHORITY TO AN AGENT UNDER POWER OF ATTORNEY, INCLUDING THE ABILITY TO GIVE AWAY ALL OF YOUR PROPERTY WHILE YOUR ARE

ALIVE OR TO SUBSTANTIALLY CHANGE HOW YOUR PROPERTY IS DISTRIBUTED AT YOUR DEATH. BEFORE SIGNING THIS DOCUMENT, YOU SHOULD SEEK THE ADVICE OF AN ATTORNEY AT LAW TO MAKE SURE YOU UNDERSTAND IT. A COURT CAN TAKE AWAY THE POWERS OF YOUR AGENT IF IT FINDS YOUR AGENT IS NOT ACTING PROPERLY.THE POWERS AND DUTIES OF AN AGENT UNDER A POWER OF ATTORNEY ARE EXPLAINED MORE FULLY IN 20 PA.C.S. CH. 56.IF THERE IS ANYTHING ABOUT THIS FORM THAT YOU DO NOT UNDERSTAND, YOU SHOULD ASK A LAWYER OF YOUR OWN CHOOSING TO EXPLAIN IT TO YOU.I HAVE READ OR HAD EXPLAINED TO ME THIS NOTICE AND I UNDERSTAND ITS CONTENTS.

AGENT ACKNOWLEDGMENTI ACKNOWLEDGE THAT I HAVE READ THE ATTACHED POWER OF ATTORNEY AND AM THE PERSON IDENTIFIED AS THE AGENT FOR THE PRINCIPAL. I HEREBY

ACKNOWLEDGE THAT WHEN I ACT AS AGENT:I SHALL ACT IN ACCORDANCE WITH THE PRINCIPAL’S REASONABLE EXPECTATIONS TO THE EXTENT ACTUALLY KNOWN BY

ME AND, OTHERWISE, IN THE PRINCIPAL’S BEST INTEREST, ACT IN GOOD FAITH AND ACT ONLY WITHIN THE SCOPE OF AUTHORITY GRANTED TO ME BY THE PRINCIPAL IN THE POWER OF ATTORNEY.

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Notice for Michigan Residents Pursuant to MCLS § 700.5501 (2012).

Important Notice to Attorney(s)-in-FactThis notice must be read and signed by the Attorney(s)-in-Fact. I, have been appointed as Attorney-in-Fact for the principal, under a durable power of attorney dated . By signing this document, I acknowledge that if and when I act as Attorney(s)-in-Fact, all the following apply:• Except as provided in the durable power

of attorney, I must act in accordance withthe standards of care applicable to fidu-ciaries acting under durable powers ofattorney.

• I must take reasonable steps to follow theinstructions of the principal.

• Upon request of the principal, I must keepthe principal informed of my actions.I must provide an accounting to theprincipal upon request of the principal, toa guardian or conservator appointed onbehalf of the principal upon the request ofthat guardian or conservator, or pursuantto judicial order.

• I cannot make a gift from the principal’sproperty, unless provided for in thedurable power of attorney or by judicialorder

• Unless provided in the durable power ofattorney or by judicial order, I, while act-ing as Attorney-in-Fact, shall not create anaccount or other asset in joint tenancybetween the principal and me.

• I must maintain records of my transactionsas Attorney-in-Fact, including receipts,disbursements, and investments.

• I may be liable for any damage or loss tothe principal, and may be subject to anyother available remedy, for breach offiduciary duty owed to the principal. In thedurable power of attorney, the principalmay exonerate me of any liability to theprincipal for breach of fiduciary dutyexcept for actions committed by me inbad faith or with reckless indifference. Anexoneration clause is not enforceable ifinserted as the result of my abuse of afiduciary or confidential relationship to theprincipal.

• I may be subject to civil or criminalpenalties if I violate my duties to theprincipal.

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Notice for Michigan Residents Pursuant to MCLS § 700.5501 (2012).

Important Notice to Attorney(s)-in-FactThis notice must be read and signed by the Attorney(s)-in-Fact. I, have been appointed as Attorney-in-Fact for the principal, under a durable power of attorney dated . By signing this document, I acknowledge that if and when I act as Attorney(s)-in-Fact, all the following apply:• Except as provided in the durable power

of attorney, I must act in accordance withthe standards of care applicable to fidu-ciaries acting under durable powers ofattorney.

• I must take reasonable steps to follow theinstructions of the principal.

• Upon request of the principal, I must keepthe principal informed of my actions.I must provide an accounting to theprincipal upon request of the principal, toa guardian or conservator appointed onbehalf of the principal upon the request ofthat guardian or conservator, or pursuantto judicial order.

• I cannot make a gift from the principal’sproperty, unless provided for in thedurable power of attorney or by judicialorder

• Unless provided in the durable power ofattorney or by judicial order, I, while act-ing as Attorney-in-Fact, shall not create anaccount or other asset in joint tenancybetween the principal and me.

• I must maintain records of my transactionsas Attorney-in-Fact, including receipts,disbursements, and investments.

• I may be liable for any damage or loss tothe principal, and may be subject to anyother available remedy, for breach offiduciary duty owed to the principal. In thedurable power of attorney, the principalmay exonerate me of any liability to theprincipal for breach of fiduciary dutyexcept for actions committed by me inbad faith or with reckless indifference. Anexoneration clause is not enforceable ifinserted as the result of my abuse of afiduciary or confidential relationship to theprincipal.

• I may be subject to civil or criminalpenalties if I violate my duties to theprincipal.

Notice for Michigan Residents continues on next page.Notice for Michigan Residents continues on next page.


• I must take reasonable steps to follow the instructions of the principal.

• Upon request of the principal, I must keep the principal informed of my actions. I must provide an accounting to the principal upon request of the principal, to a guardian or conservator appointed on behalf of the principal upon the request of that guardian or conservator, or pursuant to judicial order.

• I cannot make a gift from the principal’s property, unless provided for in the durable power of attorney or by judicial order

• Unless provided in the durable power of attorney or by judicial order, I, while acting as Attorney(s)-in-Fact, shall not createan account or other asset in joint tenancy between the principal and me.

• I must maintain records of my transactions as Attorney(s)-in-Fact, including receipts, disbursements, and investments.

• I may be liable for any damage or loss to the principal, and may be subject to any other available remedy, for breach of

durable power of attorney, the principal may exonerate me of any liability to the

except for actions committed by me in bad faith or with reckless indifference. An exoneration clause is not enforceable if inserted as the result of my abuse of a

sprincipal.

• I may be subject to civil or criminal penalties if I violate my duties to the principal.

This notice must be read and signed by the Attorney(s)-in-Fact.I,have been appointed as Attorney(s)-in-Factfor the principal, under a durable power ofattorney dated . By signingthis document, I acknowledge that if andwhen I act as Attorney(s)-in-Fact, all thefollowing apply:• Except as provided in the durable power

of attorney, I must act in accordance with the standards of care applicable to

s s of attorney.

Important Notice to Attorney(s)-in-Fact

attorney in fact affidavit and indemnification form

Documents