CLEAR PRINT

Contribution Transmittal Form Page 1 of 2

www.schwab.com 1-800-435-4000 (inside the U.S.) +1-415-667-8400 (outside the U.S.) 1-888-686-6916 (multilingual services)
1-800-515-2157 (Schwab Alliance for clients of Investment Advisors)

• This form is to be used by Employers when making contributions for participants - including business owner.
• Employers are responsible for the accuracy of the participants' account numbers and contribution amounts. To allow for timely processing, be sure
to complete all requested information. This form is not to be used to place trade instructions.
• If Roth contributions are permitted in your plan, the participant may have two (2) accounts: one for pre-tax contributions and a second one for the
Roth contributions. Be sure to list the Roth contributions with the Roth account number.

• Please use Adobe® Reader® to complete this form.

• Make your checks payable to Charles Schwab & Co., Inc.

1. Employer Information

Business Name of Employer Employer's Federal Tax ID Number (TIN)

Business Street Address City State Zip Code Business Telephone Number

Plan/Account Type (choose one only)

Individual 401(k) QRP Money Purchase QRP Profit Sharing SEP IRA
Company Retirement Account (including Pension Trust) Master funding account # (if applicable)
For SIMPLE IRA contributions, please complete the SIMPLE IRA Contribution Transmittal Form instead of this form.

2. Contribution Information
For internal transfers (journals) please provide the delivering account number.

IRS regulation requires Schwab to report SEP contributions for the year in which received. Contributions for qualified plans (Individual 401(k)/
MPP/PSP) are not reported to the IRS.

Employee's For Roth

Elective Deferral Employer
Employee Name Schwab Account Contributions (check Total Contribution
Contribution Contribution
Number below)

Example: Ann Smith XXXX-XXXX $250.00 $250.00 $500.00

Example: Ann Smith Roth 2222-2222 ✔ $200.00 $200.00 $400.00

$ $ $

$ $ $

$ $ $

$ $ $

©2023 Charles Schwab & Co., Inc. All rights reserved. Member SIPC.
(0923-3YMW) APP30709-07 (12/23)
 Contribution Transmittal Form Page 2 of 2

Employee's For Roth

Elective Deferral Employer
Employee Name Schwab Account Contributions (check Total Contribution
Contribution Contribution
Number below)

$ $ $

$ $ $

$ $ $

$ $ $

$ $ $

$ $ $

$ $ $

$ $ $

$ $ $

$ $ $

$ $ $

Totals* $ $ $

*To ensure timely processing, the Total Contribution amount must match the amount of your enclosed check.

3. Employer Authorization
I authorize and direct Schwab to deposit the dollar amounts as designated above. I understand that it is my responsibility to ensure that the
contribution instructions are correct and submitted to Schwab in a timely manner. I agree that Schwab will not be held responsible for delays in
depositing contributions if Schwab finds the contribution instructions unclear or incomplete. I indemnify and hold Schwab harmless for any loss,
claim, expense or other liability that may arise from Schwab acting upon my instructions and complying with any applicable laws and regulations
that require reporting of contributions.
Signature and Date Required

✘ signer1_SignHere signer1_DocuSignFullName signer1_DateSigned

Signature: Employer or Authorized Representative of Employer Print Name Today's Date (mm/dd/yyyy)

4. Return Instructions
Return the signed, completed form to your nearest Schwab branch (visit www.schwab.com/branch for locations), to your Investment Advisor, if
applicable, or mail it to any of the following addresses:
Regular Mail (West) Overnight Mail (West) Regular Mail (East) Overnight Mail (East)
Charles Schwab & Co., Inc. Charles Schwab & Co., Inc. Charles Schwab & Co., Inc. Charles Schwab & Co., Inc.
Attn: Document Control Attn: Document Control Attn: Document Control Attn: Document Control
P.O. Box 982600 1945 Northwestern Drive P.O. Box 628291 1958 Summit Park Dr., Ste. 200
El Paso, TX 79998-2600 El Paso, TX 79912 Orlando, FL 32862-8291 Orlando, FL 32810

©2023 Charles Schwab & Co., Inc. All rights reserved. Member SIPC.
(0923-3YMW) APP30709-07 (12/23) PRINT