Fidelity Investments Transfer/Rollover Form Completed Form Examples and Samples
Browse real-world Fidelity Investments Transfer/Rollover Form examples and samples. See step-by-step filled-out forms for 401(k) rollovers to Traditional IRA, Roth IRA conversions, direct transfers, and more. Learn how to correctly complete each section of the Fidelity Transfer/Rollover Form to avoid tax penalties and processing delays.
Fidelity Investments Transfer/Rollover Form Example – 401(k) Rollover to Traditional IRA
How this form was filled:
This example shows how a departing employee completes the Fidelity Transfer/Rollover Form to move a 401(k) balance from a former employer's plan directly into a Fidelity Traditional IRA. The form captures the account owner's personal details, the delivering institution's information, the receiving Fidelity IRA account number, the rollover type, and the transfer amount. A direct rollover is selected to avoid mandatory 20% withholding, and the form is signed and dated.
Information used to fill out the document:
- Account Owner Full Name: James R. Mitchell
- Social Security Number (SSN): XXX-XX-4782
- Date of Birth: 03/14/1978
- Phone Number: 617-555-0193
- Mailing Address: 44 Birchwood Lane, Concord, MA 01742
- Fidelity Receiving Account Type: Traditional IRA
- Fidelity Receiving Account Number: Z48-391027
- Delivering Institution Name: Horizon Manufacturing Inc. 401(k) Plan
- Delivering Institution Custodian: Vanguard Institutional Services
- Delivering Institution Phone: 800-555-0242
- Delivering Institution Address: 100 Vanguard Blvd, Malvern, PA 19355
- Delivering Account Number: 401K-HMI-77654
- Account Type at Delivering Institution: 401(k) – Former Employer Plan
- Transfer/Rollover Type: Direct Rollover (Trustee-to-Trustee)
- Amount to Transfer: Full Account Balance – $87,450.00
- Reason for Distribution: Separation from Service
- Date of Separation: 11/30/2025
- Federal Tax Withholding Election: No Withholding (Direct Rollover)
- State Tax Withholding Election: No Withholding
- Liquidation Instructions: Liquidate all holdings and transfer as cash
- Signature: James R. Mitchell
- Date Signed: 01/08/2026
What this filled form sample shows:
- Correctly identified receiving account type as Traditional IRA to match the pre-tax 401(k) source and avoid taxable event
- Selected Direct Rollover (Trustee-to-Trustee) to prevent mandatory 20% federal tax withholding
- Full account balance rollover of $87,450.00 specified with liquidation of all holdings
- Complete delivering institution details including custodian name, address, phone, and account number
- Proper separation from service noted as the qualifying distribution reason with correct separation date
- Both federal and state tax withholding set to none, appropriate for a direct rollover
- Form signed and dated in January 2026, within the recommended timeframe after separation
Form specifications and details:
| Use Case: | Direct 401(k) rollover to Fidelity Traditional IRA after leaving an employer |
| Form Name: | Fidelity Investments Transfer/Rollover/Exchange Form |
| Rollover Type: | Direct Rollover – Trustee-to-Trustee Transfer |
| Source Account Type: | 401(k) – Former Employer Sponsored Plan |
| Destination Account Type: | Traditional IRA |
| Transfer Amount: | Full Balance ($87,450.00) |
| Tax Implication: | No immediate tax liability when processed as a direct rollover |
| 60-Day Rule Applicable: | No – Direct Rollover bypasses the 60-day indirect rollover rule |
| Withholding Required: | No – Direct Rollovers are exempt from mandatory 20% withholding |
| Typical Processing Time: | 5–10 business days after receiving institution accepts the form |
| Who Should Use This Example: | Employees who have left a job and want to consolidate retirement savings into a Fidelity IRA |
Created: February 25, 2026 05:54 AM
