Fidelity Advisor IRA Distribution Request for Automatic Rollover Accounts Completed Form Examples and Samples
Find clear, filled-out examples and samples of the Fidelity Advisor IRA Distribution Request for Automatic Rollover Accounts. Our guide helps you correctly complete the form for full distributions, tax withholding, and direct deposit.
Fidelity Advisor IRA Distribution Request for Automatic Rollover Accounts Example
How this form was filled:
This sample shows how to complete the Fidelity Advisor IRA Distribution Request form for a person under age 59½ who is taking a full cash distribution from an Automatic Rollover IRA. It includes selections for full liquidation, mandatory federal and state tax withholding, and payment via direct deposit.
Information used to fill out the document:
- Account Owner: Jane A. Smith
- Date of Birth: 06/15/1985
- Fidelity IRA Account Number: Z12-345678
- Address: 456 Oak Avenue, Anytown, USA 12345
- Phone Number: (555) 123-4567
- Distribution Type: Full Distribution (Liquidate Entire Account)
- Reason for Distribution: Early Withdrawal (Under Age 59½)
- Federal Tax Withholding: 10% (Mandatory for eligible rollover distributions)
- State Tax Withholding: 5% (Elected)
- Payment Method: Direct Deposit (EFT) to a Checking Account
- Bank Name: Anytown Financial Bank
- Bank ABA/Routing Number: 987654321
- Bank Account Number: 1122334455
- Signature Date: 10/28/2026
What this filled form sample shows:
- Clearly indicates a **full distribution** to liquidate and close the entire IRA.
- Correctly filled for an account holder **under age 59½**, acknowledging it's an early distribution.
- Shows election of both mandatory **federal tax withholding** and optional **state tax withholding**.
- Provides complete information for a secure and fast **Direct Deposit (EFT)** payment.
Form specifications and details:
| Use Case: | Early, Non-Qualified Full Distribution from an Automatic Rollover IRA |
| Form Name: | Fidelity Advisor IRA Distribution Request for Automatic Rollover Accounts |
| Distribution Age: | Under 59½ |
| Distribution Amount: | Full Account Balance |
| Tax Treatment: | Early withdrawal subject to income tax and potential 10% penalty |
Created: February 25, 2026 06:40 PM
