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.
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Completed Fidelity Advisor IRA Distribution Request for Automatic Rollover Accounts form showing a direct rollover to a new employer's 401(k) plan

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
Categories: distribution forms, distribution request forms, Fidelity forms, IRA account forms, IRA distribution forms, IRA rollover forms, IRA forms, rollover forms
Created: February 25, 2026 05:58 AM
Completed Fidelity Advisor IRA Distribution Request for Automatic Rollover Accounts form showing a direct rollover to a new employer's 401(k) plan