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

Browse real-world examples of completed Fidelity Advisor 403(b) Distribution Request Forms, including early retirement distributions, rollovers, hardship withdrawals, and more. Each sample shows exactly how to fill out the form correctly with step-by-step field-by-field guidance.
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Completed Fidelity Advisor 403(b) Distribution Request Form for an early retirement partial lump-sum distribution

Fidelity Advisor 403(b) Distribution Request Form Example – Early Retirement Distribution

How this form was filled:

A 57-year-old public school teacher requests a partial lump-sum distribution from her 403(b) account upon early retirement. The form shows a direct rollover of a portion of funds to a Traditional IRA and a cash distribution for the remainder, with federal and state withholding elections and direct deposit instructions properly completed.

Information used to fill out the document:

  • Account Owner Full Name: Margaret L. Thompson
  • Social Security Number: XXX-XX-4872
  • Date of Birth: 03/14/1968
  • Address: 4821 Willow Creek Drive, Sacramento, CA 95814
  • Phone Number: (916) 555-0193
  • Email Address: [email protected]
  • Employer / Plan Name: Riverside Unified School District 403(b) Plan
  • Account Number: 403-887-22941
  • Reason for Distribution: Separation from Service (Early Retirement)
  • Date of Separation: 01/31/2026
  • Age at Distribution: 57
  • Distribution Type: Partial Lump-Sum Distribution
  • Total Distribution Amount Requested: $45,000.00
  • Rollover Amount (Direct Rollover to Traditional IRA): $30,000.00
  • Rollover Destination Institution: Fidelity Investments
  • Rollover Destination Account Number: IRA-556-009-3341
  • Cash Distribution Amount: $15,000.00
  • Federal Income Tax Withholding Election: Withhold 20% (mandatory on eligible rollover distribution cash portion)
  • State Income Tax Withholding Election: Withhold 10% (California)
  • Payment Method: Direct Deposit
  • Bank Name: Pacific Coast Credit Union
  • Bank Routing Number: 321180379
  • Bank Account Number: XXXXXX7842
  • Bank Account Type: Checking
  • Medallion Signature Guarantee: Not Required
  • Signature: Margaret L. Thompson
  • Date Signed: 02/10/2026
  • Financial Advisor Name: Robert J. Castillo
  • Financial Advisor Rep Code: RC-4471
  • Broker-Dealer: Fidelity Advisor Services

What this filled form sample shows:

  • Correctly completed account owner information including date of birth and Social Security Number for identity verification
  • Properly documented reason for distribution as Separation from Service due to early retirement at age 57
  • Partial lump-sum distribution split between a direct rollover to a Traditional IRA ($30,000) and a taxable cash distribution ($15,000)
  • Accurate mandatory 20% federal withholding applied to the eligible rollover cash portion per IRS regulations
  • California state income tax withholding elected at 10% on the cash distribution amount
  • Direct deposit payment instructions completed with bank routing and account numbers for the cash portion
  • Financial advisor information including rep code and broker-dealer details properly filled in
  • Form signed and dated with separation date documented to establish eligibility for the distribution

Form specifications and details:

Use Case: Early retirement partial lump-sum distribution with split rollover and cash payout
Plan Type: 403(b) – Public School District
Participant Age: 57 (under 59½, separation from service rule applies)
Distribution Reason: Separation from Service – Early Retirement
Distribution Method: Partial Distribution – Split (Rollover + Cash)
Rollover Type: Direct Rollover to Traditional IRA
Federal Withholding: 20% mandatory on cash portion of eligible rollover distribution
State Withholding: 10% California state income tax
Payment Delivery: Direct Deposit – Checking Account
Early Withdrawal Penalty: Potentially exempt under IRS Rule 72(t) separation from service at age 55+
Advisor Involvement: Yes – Financial Advisor Rep Code included
Form Version Targeted: Fidelity Advisor 403(b) Distribution Request Form
Categories: 403(b) forms, distribution forms, distribution request forms, Fidelity forms
Created: February 25, 2026 05:56 AM
Completed Fidelity Advisor 403(b) Distribution Request Form for an early retirement partial lump-sum distribution