Fidelity Investment-Only (Non-Prototype) Retirement Account Application Completed Form Examples and Samples

Browse filled examples and samples of the Fidelity Investment-Only (Non-Prototype) Retirement Account Application. Each example includes step-by-step completed fields, real-world scenarios, and expert guidance for small business owners, trustees, HR professionals, and financial advisors setting up non-prototype retirement plans.
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Completed Fidelity Investment-Only Non-Prototype Retirement Account Application for a small business establishing a 401(k) plan

Fidelity Investment-Only (Non-Prototype) Retirement Account Application Example – Small Business 401(k)

How this form was filled:

This example shows how a small business owner completes the Fidelity Investment-Only (Non-Prototype) Retirement Account Application to establish a 401(k) plan for their company. The application includes the employer's business information, plan details, trustee designation, investment selections, and required signatures. This sample is useful for HR professionals, small business owners, and financial advisors looking for a real-world reference.

Information used to fill out the document:

  • Employer / Plan Sponsor Name: Meridian Landscape Solutions LLC
  • Employer EIN: 47-3821056
  • Employer Address: 842 Pinecrest Boulevard, Austin, TX 78701
  • Employer Phone Number: (512) 555-0194
  • Plan Name: Meridian Landscape Solutions LLC 401(k) Profit Sharing Plan
  • Plan Number: 001
  • Plan Type: 401(k) Profit Sharing Plan
  • Plan Effective Date: 01/01/2025
  • Plan Year End: December 31
  • Number of Eligible Employees: 14
  • Trustee Name: Carlos R. Mendoza
  • Trustee Title: Owner & CEO
  • Trustee Address: 842 Pinecrest Boulevard, Austin, TX 78701
  • Trustee Phone Number: (512) 555-0194
  • Trustee SSN / EIN: 47-3821056
  • Investment Account Type: Non-Prototype Retirement Account
  • Selected Fund 1: Fidelity 500 Index Fund (FXAIX)
  • Selected Fund 2: Fidelity Total Market Index Fund (FSKAX)
  • Selected Fund 3: Fidelity U.S. Bond Index Fund (FXNAX)
  • Initial Contribution Amount: $25,000.00
  • Contribution Type: Employer Profit Sharing Contribution
  • Authorized Signer Name: Carlos R. Mendoza
  • Authorized Signer Title: Owner & CEO
  • Signature Date: 03/10/2025
  • Existing Plan Document: Yes – maintained by third-party TPA
  • Third-Party Administrator (TPA) Name: Summit Retirement Plan Services
  • TPA Phone Number: (800) 555-0372

What this filled form sample shows:

  • Correctly identified plan type as a 401(k) Profit Sharing Plan with a plan number and effective date of January 1, 2025
  • Properly completed employer and plan sponsor information including EIN, address, and phone number for Meridian Landscape Solutions LLC
  • Accurate trustee designation with the owner serving as sole trustee, including title and contact details
  • Appropriate selection of Non-Prototype account type, reflecting that the plan is governed by an independently maintained plan document
  • Realistic fund selections across equity and fixed income Fidelity index funds (FXAIX, FSKAX, FXNAX)
  • Initial employer profit sharing contribution of $25,000 documented with proper contribution type classification
  • Reference to a third-party administrator (TPA), Summit Retirement Plan Services, consistent with non-prototype plan structure
  • Properly signed and dated by the authorized plan trustee on March 10, 2025

Form specifications and details:

Use Case: Small business establishing a 401(k) Profit Sharing Plan using a non-prototype plan document
Plan Type: 401(k) Profit Sharing Plan
Account Type: Investment-Only (Non-Prototype) Retirement Account
Business Structure: Limited Liability Company (LLC)
Number of Employees: 14
Trustee Structure: Single trustee (business owner)
Plan Document Source: Third-party administrator (TPA)
Investment Strategy: Diversified index fund portfolio
Contribution Type: Employer Profit Sharing
Form Purpose: Open a Fidelity brokerage/mutual fund account to hold assets of an existing qualified retirement plan
Applicable Year: 2025
Categories: account application forms, Fidelity forms, investment account forms, investment application forms, investment forms, retirement account forms, retirement forms, UK investment forms
Created: February 25, 2026 06:17 AM
Completed Fidelity Investment-Only Non-Prototype Retirement Account Application for a small business establishing a 401(k) plan