Fidelity Advisor 403(b) Distribution Request Form Completed Form Examples and Samples

Explore clear, filled-out examples of the Fidelity Advisor 403(b) Distribution Request Form. Our detailed samples and guides help you correctly complete the form for rollovers, cash withdrawals, and other distributions.
Fidelity Advisor 403(b) Distribution Request Form has a moderate Form Complexity Index of 60/100 — Instafill’s AI completes it in under a minute.
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Completed Fidelity Advisor 403(b) Distribution Request Form showing a direct rollover to an IRA.

Fidelity Advisor 403(b) Distribution Request Form Example - Rollover

How this form was filled:

This example shows how a former employee, age 60, completes the Fidelity Advisor 403(b) Distribution Request Form to execute a full, direct rollover to a Traditional IRA. Key sections include personal information, reason for distribution (Separation from Service), and detailed instructions for a non-taxable direct rollover to another financial institution.

Information used to fill out the document:

  • Participant Name: Jane M. Smith
  • Social Security Number: XXX-XX-1234
  • Date of Birth: 05/10/1965
  • Address: 456 Oak Avenue, Anytown, USA 54321
  • Phone Number: (555) 123-4567
  • Former Employer: Anytown School District
  • Plan Number: 98765
  • Date of Separation: 06/30/2025
  • Reason for Distribution: Separation from Service (Age 55 or older)
  • Distribution Amount: Full Distribution (100%)
  • Distribution Method: Direct Rollover to a Traditional IRA
  • Receiving Firm: Fidelity Personal Investing
  • Receiving Account Number: Z12-345678
  • Signature Date: 03/15/2026

What this filled form sample shows:

  • Clearly identifies the participant and their 403(b) plan information.
  • Specifies 'Separation from Service' as the qualifying event for distribution.
  • Selects a Full Distribution to be processed as a Direct Rollover, a common non-taxable event.
  • Provides complete information for the receiving financial institution to ensure accurate fund transfer.
  • Includes a valid signature and date, with the date set in the near future (2026).

Form specifications and details:

Form Name: Fidelity Advisor 403(b) Distribution Request Form
Use Case: Direct Rollover to a Traditional IRA after Separation from Service
Participant Age: Over 59 ½
Categories: 403(b) forms, distribution forms, distribution request forms
Created: February 25, 2026 06:37 PM
Completed Fidelity Advisor 403(b) Distribution Request Form showing a direct rollover to an IRA.