Fidelity Distribution—Rollover Instructions
This form contains 87 fields organized into 18 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Account Owner/Participant Details | ||
| 1st Account Owner/Participant Name | Text |
Provide the full name of the first account owner or participant.
|
| 1st Account Owner/Participant Social Security or Taxpayer ID Number | Text |
Enter the Social Security Number or Taxpayer Identification Number of the first account owner or participant.
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| 1st Account Owner/Participant Date of Birth | Date |
Enter the date of birth for the first account owner or participant.
|
| 1st Account Owner/Participant Evening Phone | Text |
Provide the first account owner or participant's evening phone number.
|
| 1st Account Owner/Participant Daytime Phone | Text |
Provide the first account owner or participant's daytime phone number.
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| 1st Account Owner/Participant Email | Text |
Enter the email address for the first account owner or participant.
|
| Not married | Radiobutton |
Check this box if the account owner or participant is not married.
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| Married | Radiobutton |
Check this box if the account owner or participant is married, noting that their spouse may need to sign this form.
|
| Reason for Distribution-Current_Current#20employees:#20qualified#20by#20age | RadioButton | |
| Reason for Distribution-Current_current#20employees:#20disability | RadioButton | |
| Reason for Distribution-Current_Current#20employees:#20other | RadioButton | |
| Reason for Distribution-Former_Former#20employees:#20separation#20from#20service | RadioButton | |
| Reason for Distribution-Former_Former#20employees:#20disability | RadioButton | |
| Employer and Plan Information | ||
| Plan Sponsor Name | Text |
Enter the full legal name of the plan sponsor associated with the plan(s) involved.
|
| First Plan Number | Text |
Provide the first plan number for a plan sponsored by the employer.
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| Second Plan Number | Text |
Provide the second plan number for a plan sponsored by the employer.
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| Third Plan Number | Text |
Provide the third plan number for a plan sponsored by the employer.
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| Fourth Plan Number | Text |
Provide the fourth plan number for a plan sponsored by the employer.
|
| General | ||
| Enter spouse signature | Signature | |
| Enter notary or plan representative signature | Signature | |
| Enter participant signature | Signature | |
| Enter signature guarantee | Signature | |
| Enter plan representative signature | Signature | |
| Non-Roth Assets Destination | ||
| Destination_I#20would#20like#20to#20move#20my#20plan#20assets#20to#20a#20retirement#20account#20for#20non-Roth#20assets | RadioButton | |
| Non-Roth Assets Rollover IRA | Radiobutton |
Check this box if you want to designate a Rollover IRA as the destination for your non-Roth assets.
|
| Non-Roth Assets Roth IRA | Radiobutton |
Check this box if you want to designate a Roth IRA as the destination for your non-Roth assets, which will be considered a conversion and may result in taxes.
|
| Non-Roth Assets Employer-Sponsored Plan | Radiobutton |
Check this box if you want to designate an Employer-sponsored plan as the destination for your non-Roth assets.
|
| Non-Roth Assets Investment Provider or Plan Name | Text |
Enter the name of the investment provider or employer-sponsored plan for the non-Roth assets destination.
|
| Non-Roth Assets Fidelity Account Number | Text |
Enter the Fidelity account number for the non-Roth assets destination, if applicable.
|
| Non-Roth Send_I#20would#20like#20non-roth#20after-tax#20contributions#20sent#20directly#20to#20me#20by#20check | RadioButton | |
| Non-Roth Send_I#20would#20like#20to#20rollover#20a#20percentage#20of#20pre-tax#20assets#20and#20send#20the#20rest#20including#20any#20after-ta#94#02 | RadioButton | |
| Destination_I#20would#20like#20to#20move#20all#20plan#20assets#20to#20a#20retirement#20account#20for#20Roth#20assets | RadioButton | |
| Non-Roth Percentage Rollover | ||
| Non-Roth Rollover Percentage | Number |
Enter the percentage of non-Roth assets to be rolled over.
|
| Roth_I#20would#20like#20roth#20IRA | RadioButton | |
| Roth_I#20would#20like#20employer-sponsored#20plan | RadioButton | |
| Notarization or Plan Representative Witness | ||
| Notarization State | Text |
Enter the state where the notarization or witnessing occurs.
|
| Notarization County | Text |
Enter the county where the notarization or witnessing occurs.
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| Identification Provided | Text |
Provide the type of identification used by the individual.
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| Date of Notarization | Date |
Enter the date when the notarization or witnessing took place.
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| Notary/Representative Printed Name | Text |
Enter the printed name of the Notary or Plan Representative.
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| Notary/Representative Signature Date | Date |
Enter the date the Notary or Plan Representative signed.
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| Notary Commission Expiration Date | Date |
Enter the date when the notary's commission expires.
|
| Partial Rollover Non-Roth Assets Destination | ||
| Partial Rollover Non-Roth Investment Provider or Employer-Sponsored Plan Name | Text |
Enter the name of the investment provider or employer-sponsored plan for the partial rollover of non-Roth assets.
|
| Partial Rollover Non-Roth Fidelity Account Number | Text |
Enter the Fidelity account number, if applicable, for the partial rollover of non-Roth assets.
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| Partial Rollover Roth Assets Destination | ||
| Partial Rollover Roth Assets Investment Provider Name | Text |
Enter the name of the investment provider or employer-sponsored plan for the partial rollover of Roth assets.
|
| Partial Rollover Roth Assets Fidelity Account Number | Text |
Enter the Fidelity account number for the partial rollover of Roth assets, if applicable.
|
| Partial Rollover Source Asset Selection | ||
| Employer-sponsored plan (non-Roth assets) | Radiobutton |
Check this box if non-Roth assets from the partial rollover are being designated to an Employer-sponsored plan.
|
| Retirement account for Roth assets | Radiobutton |
Check this box if you are designating a retirement account as the destination for Roth assets in this partial rollover.
|
| Roth IRA (Roth assets) | Radiobutton |
Check this box if Roth assets from the partial rollover are being designated to a Roth IRA.
|
| Employer-sponsored plan (Roth assets) | Radiobutton |
Check this box if Roth assets from the partial rollover are being designated to an Employer-sponsored plan.
|
| Participant Address | ||
| Address Line 1 | Text |
Enter the primary street address for the participant.
|
| City | Text |
Enter the city for the participant's address.
|
| State/Province | Text |
Enter the state or province for the participant's address.
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| Zip/Postal Code | Text |
Enter the zip code or postal code for the participant's address.
|
| Country | Text |
Enter the country for the participant's address.
|
| Participant Signature | ||
| Participant Name | Text |
Please enter the printed name of the participant.
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| Participant Signature Date | Date |
Please enter the date the participant signed.
|
| Not a Medallion Signature Guarantee | Checkbox |
Check this box if the signature guarantee you are providing is NOT a Medallion signature guarantee.
|
| Plan Representative Signature | ||
| Plan Representative Printed Name | Text |
Enter the full printed name of the plan representative.
|
| Plan Representative Signature Date | Date |
Enter the date the plan representative signed this form.
|
| Plan Sponsor Approval Details | ||
| Participant's Date of Hire | Date |
Enter the participant's date of hire.
|
| Separation Date | Date |
Enter the participant's separation date, if applicable.
|
| Employer-Source Vesting Percentage | Number |
Enter the employer-source vesting percentage.
|
| Roth Assets Destination | ||
| Roth Assets Investment Provider or Employer-Sponsored Plan Name | Text |
Enter the name of the investment provider or employer-sponsored plan for Roth assets.
|
| Roth Assets Fidelity Account Number | Text |
Enter the Fidelity account number for Roth assets, if applicable.
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| Send Roth After-Tax Contributions Directly to You | Radiobutton |
Check this box if you want your Roth after-tax contributions to be sent directly to you by check, rather than included in the rollover check made out to the firm.
|
| Roth Send_I#20would#20like#20to#20rollover#20a#20precentage#20of#20pre-tax#20assets#20and#20send#20the#20rest#20including#20any#20after-ta#AA#02 | RadioButton | |
| Source_I#20would#20like#20this#20amount,#20drawn#20proportionately#20from#20all#20available#20plan#20assets | RadioButton | |
| Source_I#20would#20like#20100#25#20of#20these#20available#20plan#20assets#20only | RadioButton | |
| 100%_I#20want#20pre-tax#20#28non-Roth#29 | RadioButton | |
| 100%_I#20want#20Roth#20IRA | RadioButton | |
| Roth Percentage Rollover | ||
| Roth Rollover Percentage | Number |
Enter the percentage of Roth pre-tax assets to be rolled over.
|
| 100%_I#20want#20Roth | RadioButton | |
| Destinations_I#20would#20like#20to#20move#20my#20plan#20assets#20to#20a#20retirement#20account#20for#20Roth#20assets | RadioButton | |
| Source Amount | ||
| Source Amount | Number |
Enter the amount to be drawn proportionately from all available plan assets.
|
| Rollover IRA | Radiobutton |
Check this box if the non-Roth assets should be rolled over into a Rollover IRA.
|
| Roth IRA | Radiobutton |
Check this box if the non-Roth assets should be rolled over into a Roth IRA.
|
| Spouse's Consent | ||
| Spouse's Printed Name | Text |
Enter the spouse's full name, printed clearly.
|
| Spouse's Signature Date | Date |
Enter the date the spouse signed the form.
|
| State Tax Withholding | ||
| Withhold State Taxes at Applicable Rate | Radiobutton |
Check this box if you want to withhold state taxes at the standard applicable rate.
|
| Withhold Additional Dollar Amount | Radiobutton |
Check this box if you want to withhold an additional dollar amount in state taxes, in addition to the applicable rate.
|
| Additional State Tax Withholding Amount | Number |
Provide the additional dollar amount to withhold for state taxes, with a minimum of $10.
|
| Withhold Specific Dollar Amount (NY, NM, NJ, ND, PA, RI Only) | Radiobutton |
Check this box if you are a resident of NY, NM, NJ, ND, PA, or RI and want to withhold a specific dollar amount in state taxes.
|
| Specific State Tax Withholding Amount (NY, NM, NJ, ND, PA, RI Only) | Number |
Provide the dollar amount to withhold for state taxes, applicable only for residents of NY, NM, NJ, ND, PA, and RI, with a minimum of $10.
|
| Do NOT Withhold State Taxes | Radiobutton |
Check this box if you do not want to withhold state taxes, unless withholding is legally required.
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| Delivery Method_I#20would#20like#20to#20have#20a#20check#20sent#20to#20mailing#20address | RadioButton | |
| Delivery Method_I#20would#20like#20a#20check#20sent#20by#20UPS#20delivery.#20A#20fee#20of#20$25#20will#20be#20deducted#20from#20your#20account | RadioButton | |