Fidelity Investments Transfer/Rollover/Exchange Form Completed Form Examples and Samples

Explore real-world filled examples of the Fidelity Investments Transfer/Rollover/Exchange Form, including 401(k) rollovers to Traditional IRAs, Roth conversions, and direct transfers between institutions. Each sample shows exactly how to complete the form step by step with realistic data, helping you avoid common mistakes and submit your transfer request with confidence.
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Completed Fidelity Investments Transfer/Rollover/Exchange Form for a 401(k) direct rollover to a Traditional IRA

Fidelity Investments Transfer/Rollover/Exchange Form Example – 401(k) Rollover to Traditional IRA

How this form was filled:

This example demonstrates how a recently separated employee completes the Fidelity Investments Transfer/Rollover/Exchange Form to roll over a former employer's 401(k) plan directly into a Fidelity Traditional IRA. The form includes the account owner's personal information, the delivering institution's details, the receiving Fidelity IRA account number, the rollover type selected as 'Direct Rollover,' and the request to liquidate all assets and transfer the full balance. The form is signed and dated in 2025.

Information used to fill out the document:

  • Account Owner Full Name: Michael R. Thompson
  • Social Security Number: XXX-XX-4872
  • Date of Birth: March 14, 1979
  • Phone Number: (614) 555-0193
  • Mailing Address: 4821 Oakridge Drive, Columbus, OH 43215
  • Receiving Fidelity Account Number: 234-567890
  • Receiving Account Type: Traditional IRA
  • Delivering Institution Name: Vanguard Institutional – Hartwell Manufacturing 401(k) Plan
  • Delivering Institution Address: P.O. Box 2900, Valley Forge, PA 19482
  • Delivering Institution Phone: (800) 523-1036
  • Delivering Account Number: 401K-HM-88341
  • Delivering Account Type: 401(k) – Former Employer Plan
  • Transfer Type: Direct Rollover
  • Assets to Transfer: Full Balance – Liquidate All Holdings
  • Approximate Transfer Amount: $87,450.00
  • Reason for Distribution: Separation from Service
  • Date of Separation: November 30, 2025
  • Tax Withholding Election: No Federal or State Withholding (Direct Rollover)
  • Signature: Michael R. Thompson
  • Date Signed: January 8, 2026

What this filled form sample shows:

  • Correctly identifies the receiving Fidelity Traditional IRA account number and account type
  • Accurately documents the delivering institution (Vanguard Institutional) and former employer 401(k) plan details
  • Transfer type selected as Direct Rollover to avoid mandatory 20% federal tax withholding
  • Full balance liquidation instruction to transfer all assets from the former employer plan
  • Separation from service correctly listed as the qualifying distribution reason
  • Tax withholding set to none, appropriate for a direct rollover transaction
  • Form properly signed and dated in January 2026, reflecting a recent post-separation rollover

Form specifications and details:

Use Case: Direct 401(k) rollover to Fidelity Traditional IRA after separation from 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 Scope: Full Balance – All Assets Liquidated
Tax Withholding: None (Direct Rollover exemption applies)
Qualifying Event: Separation from Service
Approximate Account Value: $87,450.00
Form Date: January 8, 2026
Categories: Fidelity forms, investment forms, investment transfer forms, rollover forms, transfer forms, UK investment forms
Created: February 24, 2026 05:40 AM
Completed Fidelity Investments Transfer/Rollover/Exchange Form for a 401(k) direct rollover to a Traditional IRA