Fidelity Investments Transfer/Rollover/Exchange Form Completed Form Examples and Samples
Browse real-world examples of completed Fidelity Investments Transfer/Rollover/Exchange Forms, including 401(k) rollovers to Traditional IRAs, Roth conversions, and direct transfers between institutions. Each sample form walks you through every section — account owner details, delivering institution information, transfer type selection, and signature requirements — so you can complete your own Fidelity rollover or transfer with confidence in 2025 and 2026.
Fidelity Investments Transfer/Rollover/Exchange Form Example – 401(k) Rollover to Traditional IRA
How this form was filled:
This sample Fidelity Transfer/Rollover/Exchange Form illustrates how a participant rolling over a former employer's 401(k) plan into a Fidelity Traditional IRA would complete the form. The example covers account owner information, the delivering institution details, the receiving Fidelity account, rollover type selection, and the required signature section — making it a practical reference for anyone initiating a direct rollover in 2025 or 2026.
Information used to fill out the document:
- Account Owner Full Name: Michael T. Reynolds
- Social Security Number: XXX-XX-4872
- Date of Birth: March 14, 1979
- Phone Number: (614) 555-0193
- Mailing Address: 4821 Oakwood Drive, Columbus, OH 43215
- Email Address: [email protected]
- Delivering Institution Name: Vanguard Fiduciary Trust Company
- Delivering Institution Address: P.O. Box 2900, Valley Forge, PA 19482
- Delivering Institution Phone: (800) 523-1036
- Account Number at Delivering Institution: 78234-09156
- Account Type at Delivering Institution: 401(k) – Former Employer Plan
- Former Employer / Plan Name: Hartwell Manufacturing Group 401(k) Plan
- Transfer Amount: Full Account Balance (estimated $84,500.00)
- Transfer Type: Direct Rollover
- Liquidation Instructions: Liquidate all holdings and transfer as cash
- Receiving Fidelity Account Number: Z48-291047
- Receiving Fidelity Account Type: Traditional IRA
- Investment Instructions for Rollover Proceeds: Fidelity 500 Index Fund (FXAIX) – 100%
- Reason for Rollover: Separation from service / change of employment
- Withholding Election: No federal tax withholding (direct rollover)
- Signature: Michael T. Reynolds
- Date Signed: January 22, 2026
- Medallion Signature Guarantee: Not required for this transaction
What this filled form sample shows:
- Correctly identified account owner information including SSN, date of birth, and current mailing address
- Accurately completed delivering institution section with Vanguard's plan trustee name, address, and the participant's 401(k) account number
- Proper selection of Direct Rollover as the transfer type to avoid mandatory 20% federal withholding
- Full account balance rollover with liquidation of all holdings prior to transfer
- Designated Fidelity Traditional IRA as the receiving account to maintain tax-deferred status
- Specified investment allocation of rollover proceeds into Fidelity 500 Index Fund (FXAIX)
- Correctly elected no federal tax withholding consistent with a direct rollover transaction
- Properly executed signature and date fields completed in January 2026
Form specifications and details:
| Form Name: | Fidelity Investments Transfer/Rollover/Exchange Form |
| Use Case: | Direct 401(k) rollover to Fidelity Traditional IRA upon separation from service |
| Account Owner: | Individual (former employee) |
| Source Account Type: | 401(k) – Former Employer Sponsored Plan |
| Destination Account Type: | Traditional IRA |
| Rollover Method: | Direct Rollover (trustee-to-trustee transfer) |
| Transfer Amount: | Full balance (~$84,500) |
| Tax Implication: | No taxable event if direct rollover is completed properly |
| Withholding: | None elected (0% federal withholding) |
| Form Version Applicable: | Current as of 2025–2026 |
| Medallion Guarantee Required: | No |
| Estimated Processing Time: | 5–7 business days after delivering institution approval |
Created: February 24, 2026 04:05 AM
