Fidelity Advisor IRA Distribution Request for Automatic Rollover Accounts Completed Form Examples and Samples
Explore real-world filled examples of the Fidelity Advisor IRA Distribution Request for Automatic Rollover Accounts form. Each sample walks you through how to correctly complete the form for direct rollovers, partial distributions, and more — with step-by-step field-by-field guidance to help you avoid errors and process your Safe Harbor IRA distribution with confidence.
Fidelity Advisor IRA Distribution Request for Automatic Rollover Accounts Example – Direct Rollover to New Employer Plan
How this form was filled:
This example shows how a former employee completes the Fidelity Advisor IRA Distribution Request for Automatic Rollover Accounts form to roll over funds that were automatically rolled into a Safe Harbor IRA back into a new employer's 401(k) plan. The account holder requests a full distribution via direct rollover, provides the receiving plan's details, and certifies the request with a signature and date.
Information used to fill out the document:
- Account Owner Full Name: James R. Holloway
- Social Security Number: XXX-XX-4782
- Date of Birth: March 14, 1983
- Daytime Phone Number: (614) 555-0192
- Street Address: 4821 Elmwood Drive
- City: Columbus
- State: OH
- ZIP Code: 43215
- Fidelity Advisor IRA Account Number: 7732-884910
- Reason for Distribution: Rollover – Direct Rollover to Eligible Employer Plan
- Distribution Amount: Full Balance
- Estimated Account Value: $18,450.00
- Receiving Plan Name: Meridian Technologies Inc. 401(k) Retirement Plan
- Receiving Plan Trustee / Custodian: Vanguard Fiduciary Trust Company
- Receiving Plan Account Number: VG-00291847
- Receiving Plan Trustee Address: 100 Vanguard Blvd, Malvern, PA 19355
- Make Check Payable To: Vanguard Fiduciary Trust Company FBO James R. Holloway
- Federal Income Tax Withholding: No withholding elected (direct rollover)
- State Income Tax Withholding: No withholding elected (direct rollover)
- Financial Advisor / Representative Name: Sandra L. Chu
- Financial Advisor Branch Number: BR-4409
- Financial Advisor Phone: (614) 555-0340
- Owner Signature: James R. Holloway
- Signature Date: January 22, 2026
What this filled form sample shows:
- Full account owner identification including SSN, date of birth, and current address in Columbus, OH
- Distribution reason clearly marked as Direct Rollover to an Eligible Employer-Sponsored Plan
- Request for full balance distribution of the entire Safe Harbor IRA (~$18,450)
- Detailed receiving plan information including Meridian Technologies Inc. 401(k) and Vanguard as trustee/custodian
- Check made payable to Vanguard Fiduciary Trust Company FBO James R. Holloway to ensure tax-free treatment
- No federal or state income tax withholding elected, appropriate for a direct rollover transaction
- Financial advisor Sandra L. Chu listed with branch and contact details
- Form signed and dated January 22, 2026 by the account owner
Form specifications and details:
| Use Case: | Direct rollover from Fidelity Advisor Safe Harbor IRA back to a new employer's 401(k) plan |
| Form Name: | Fidelity Advisor IRA Distribution Request for Automatic Rollover Accounts |
| Account Type: | Safe Harbor IRA (Automatic Rollover IRA) |
| Distribution Type: | Full Balance – Direct Rollover |
| Original Rollover Trigger: | Automatic rollover from former employer plan due to balance under plan threshold |
| Receiving Plan Type: | Employer-Sponsored 401(k) Plan |
| Tax Treatment: | Tax-free direct rollover (no 20% mandatory withholding applies) |
| Withholding Elections: | No federal or state withholding |
| Form Completion Year: | 2026 |
| Applicable IRS Rules: | IRC Section 401(a)(31) – Direct Rollover Rules |
Created: February 25, 2026 05:58 AM
