Fidelity Distribution—Rollover Completed Form Examples and Samples
Browse real filled examples of the Fidelity Distribution—Rollover form. See sample forms completed for job change rollovers, retirement distributions, and IRA transfers — with step-by-step explanations of how each field was populated.
Fidelity Distribution—Rollover Example – Job Change Rollover to IRA
How this form was filled:
Our AI extracted retirement account and personal details from an HR offboarding email and automatically filled the Fidelity Distribution—Rollover form, correctly identifying the reason for distribution as separation from service, mapping the plan sponsor and plan number, and routing all pre-tax assets to the participant's existing Fidelity Rollover IRA.
Source document used: HR Offboarding Email Thread
Subject: RE: Your Retirement Plan Options – Action Required Hi Marcus, Hope your transition is going smoothly! As we discussed during your offboarding meeting on January 10th, now that your last day with Northgate Industrial Solutions was January 3, 2025, you'll need to decide what to do with your 401(k) balance. For our records: you were hired here on June 14, 2018, and your separation date is January 3, 2025. You are fully vested at 100% — congratulations on hitting that milestone a couple of years back. Your plan with us is the Northgate Industrial Solutions 401(k) Plan, and the plan number you'll need for any paperwork is 62-44801. We only have the one plan here, so that's the only number you'll need to reference. You mentioned during our call that you'd like to roll everything over — the full balance, all plan assets — directly into your existing Rollover IRA at Fidelity. Your Fidelity account number for that IRA is 4521-003987. Since all of your contributions have been traditional pre-tax, there are no Roth assets to worry about, so a standard Rollover IRA is the right destination. For the Fidelity form, here's the personal info they'll need: - Your full name: Marcus T. Holloway - SSN: 572-88-4931 - Date of birth: March 22, 1979 - Your current address is 847 Creekside Drive, Austin, TX 78704 - Best daytime number: (512) 664-2190; evenings you can be reached at (512) 889-4455 - Email: [email protected] - Marital status: married (your wife Rebecca will likely need to sign the spousal consent section) For tax withholding, you said you'd prefer to just let the full amount go through as a rollover so you don't want any state taxes withheld beyond what's required. Since Texas has no state income tax, that should be straightforward. Please send the completed form back to Fidelity as soon as possible — they prefer the NetBenefits app upload or regular mail to their Cincinnati PO Box. Let me know if you have any questions! Best, Denise Parrott HR Benefits Coordinator Northgate Industrial Solutions
Information used to fill out the document:
- Participant Name & SSN: Marcus T. Holloway, SSN 572-88-4931, DOB March 22, 1979
- Contact & Address: 847 Creekside Drive, Austin, TX 78704 | Daytime: (512) 664-2190 | Evening: (512) 889-4455 | [email protected]
- Marital Status: Married (spouse Rebecca may need to sign spousal consent)
- Plan Sponsor & Plan Number: Northgate Industrial Solutions, Plan No. 62-44801
- Reason for Distribution: Former employee – Separation from service (last day January 3, 2025)
- Rollover Destination: Move ALL plan assets to Rollover IRA at Fidelity, Account No. 4521-003987
- Asset Type: All pre-tax (non-Roth) assets only
- Employment Dates: Hired June 14, 2018; Separated January 3, 2025; 100% vested
- State Tax Withholding: Do NOT withhold state taxes (Texas has no state income tax)
What this filled form sample shows:
- Extracted participant name, SSN, and date of birth from a bulleted list embedded in a conversational HR email
- Identified reason for distribution as 'separation from service' from the phrase 'your last day with Northgate Industrial Solutions was January 3, 2025'
- Parsed plan sponsor name and plan number from narrative HR offboarding instructions
- Correctly routed all plan assets to a Rollover IRA based on the instruction to 'roll everything over ā the full balance'
- Mapped the Fidelity account number mentioned casually mid-paragraph to the destination account field
- Determined state tax withholding preference from the mention that Texas has no state income tax
- Captured hire date and separation date for the Plan Sponsor Approval section from HR context
Form specifications and details:
| Use Case: | Former employee rolling over full 401(k) balance to existing Fidelity Rollover IRA after job change |
| Plan Type: | 401(k) |
| Source Document: | HR offboarding email thread from benefits coordinator |
| Distribution Reason: | Separation from service |
| Asset Type: | Pre-tax (non-Roth) only |
| Rollover Destination: | Fidelity Rollover IRA |
| Marital Status: | Married (spousal consent required) |
| Categories: | rollover forms, distribution forms |
| Created: | March 10, 2026 06:02 AM |