Fidelity Investments Transfer/Rollover/Exchange Form Instructions
This form contains 89 fields organized into 27 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Contact Information | ||
| Daytime Phone | Text |
Please enter your daytime contact phone number.
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| Evening Phone | Text |
Please enter your evening contact phone number.
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| Text |
Please enter your email address.
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| Current Investment Selection Choice | ||
| Current Investment Selection - Yes | Checkbox |
Check this box if you want the assets invested in your current investment selection.
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| Current Investment Selection - No | Checkbox |
Check this box if you do not want the assets invested in your current investment selection and will specify new instructions below.
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| Employer Authorization | ||
| Date of Authorization | Date |
Enter the date the employer authorized the signature.
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| Authorized Printed Name | Text |
Enter the printed name of the employer's authorized signatory.
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| Employer Sponsoring Fidelity Retirement Account | ||
| Enter the employer sponsoring your Fidelity retirement account | Text | |
| Employer City and State | Text |
Enter the city and state of the employer.
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| Employment Status | ||
| Yes | Checkbox |
Check this box if you are still employed with the employer sponsoring your Fidelity Retirement Account.
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| No | Checkbox |
Check this box if you are no longer employed with the employer sponsoring your Fidelity Retirement Account.
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| Fidelity Account Information for 3A | ||
| 4A 403(b) | Checkbox |
Check this box if your Fidelity Account Information for 3A is a 403(b) plan type.
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| 4A 401(a)/(k) | Checkbox |
Check this box if your Fidelity Account Information for 3A is a 401(a)/(k) plan type.
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| 4A 457(b) governmental | Checkbox |
Check this box if your Fidelity Account Information for 3A is a 457(b) governmental plan type.
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| 3A Plan Number | Text |
Enter the plan number for the Fidelity account, if known, specifically for section 3A.
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| Fidelity Account Information for 3B | ||
| 3B 403(b) | Checkbox |
Check this box if the Fidelity account information for 3B is for a 403(b) plan type.
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| 3B 401(a)/(k) | Checkbox |
Check this box if the Fidelity account information for 3B is for a 401(a)/(k) plan type.
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| 3B 457(b) governmental | Checkbox |
Check this box if the Fidelity account information for 3B is for a 457(b) governmental plan type.
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| 3B Plan Number | Text |
Enter the plan number for Fidelity Account Information for 3B.
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| First Account Liquidation Amount | ||
| First Account Full Liquidation/100% | Checkbox |
Check this box if you want to liquidate 100% of the funds for the first account.
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| First Account Partial Liquidation | Checkbox |
Check this box if you want to liquidate only a portion of the funds for the first account.
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| First Account Liquidation Percentage | Number |
Enter the percentage of the first account that should be liquidated.
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| First Account Liquidation Dollar Amount | Number |
Enter the specific dollar amount of the first account that should be liquidated.
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| First Account Transaction Type | ||
| First Account The Same Employer as My Employer Plan with Fidelity | Checkbox |
Check this box if the account you are moving is associated with the same employer as your existing employer plan with Fidelity.
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| First Account A Previous Employer | Checkbox |
Check this box if the account you are moving is from a previous employer.
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| First Account A Rollover IRA | Checkbox |
Check this box if the account you are moving is a Rollover IRA.
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| First Account A Traditional IRA or SEP IRA | Checkbox |
Check this box if the account you are moving is a Traditional IRA or a SEP IRA.
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| First Account Type | ||
| First Account Type: 403(b) | Checkbox |
Check this box if the first account to be moved is a 403(b) retirement plan.
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| First Account Type: Include Roth 403(b) balance | Checkbox |
Check this box if the 403(b) account to be moved includes a Roth balance.
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| First Account Type: 401(a)/(k) | Checkbox |
Check this box if the first account to be moved is a 401(a) or 401(k) retirement plan.
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| First Account Type: Include Roth 401(k) balance | Checkbox |
Check this box if the 401(k) account to be moved includes a Roth balance.
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| First Account Type: 457(b) governmental | Checkbox |
Check this box if the first account to be moved is a governmental 457(b) deferred compensation plan.
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| First Account Type: Include Roth 457(b) governmental balance | Checkbox |
Check this box if the governmental 457(b) account to be moved includes a Roth balance.
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| First Account Type: IRA | Checkbox |
Check this box if the first account to be moved is an Individual Retirement Account (IRA).
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| First Account/Contract # | ||
| First Account/Contract Number | Text |
Please provide the account or contract number for the first account/contract.
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| First Investment Instruction | ||
| First Investment Fund Name | Text |
Enter the name of the first investment fund.
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| First Investment Fund Code | Text |
Enter the code for the first investment fund.
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| First Investment Percentage | Number |
Enter the percentage of assets to be invested in the first fund.
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| Fourth Investment Instruction | ||
| Fourth Fund Name | Text |
Enter the name of the fourth investment fund.
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| Fourth Fund Code | Text |
Enter the code for the fourth investment fund.
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| Fourth Fund Percentage | Number |
Enter the percentage of assets to be allocated to the fourth investment fund.
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| General | ||
| Enter the employer authorized signature | Signature | |
| Enter your signature | Signature | |
| Investment Provider Information | ||
| Investment Provider Name | Text |
Enter the full name of the investment provider from which you are moving money.
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| Provider Street Address | Text |
Provide the street address of the investment provider.
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| Provider City | Text |
Enter the city of the investment provider's address.
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| Provider State | Text |
Enter the state of the investment provider's address.
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| Provider ZIP Code | Text |
Enter the ZIP code of the investment provider's address.
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| Provider Phone Number | Text |
Provide the phone number of the investment provider.
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| Provider Phone Extension | Text |
Enter the extension number for the investment provider's phone.
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| Mailing Address | ||
| Mailing Street Address | Text |
Enter your complete mailing street address.
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| Mailing City | Text |
Enter the name of your mailing city.
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| Mailing State | Text |
Enter the name or abbreviation of your mailing state.
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| Mailing ZIP Code | Text |
Enter your mailing postal ZIP code.
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| Page 6 | ||
| Signature Date | Date |
Provide the date this form is signed.
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| Personal Details | ||
| Social Security Number or Tax ID | Text |
Please enter your Social Security Number (SSN) or Tax Identification Number (TIN).
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| Date of Birth | Date |
Please provide your date of birth.
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| First Name | Text |
Please enter your legal first name.
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| Middle Initial | Text |
Please enter your middle initial.
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| Last Name | Text |
Please enter your legal last name.
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| Previous Employer Name | ||
| Previous Employer Name | Text |
Provide the name of the previous employer.
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| Second Account Liquidation Amount | ||
| Second Account Full Liquidation/100% | Checkbox |
Check this box if you want to fully liquidate 100% of the second account.
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| Second Account Partial Liquidation | Checkbox |
Check this box if you want to partially liquidate the second account.
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| Second Account Liquidation Percentage | Number |
Provide the percentage of the second account you wish to liquidate.
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| Second Account Liquidation Dollar Amount | Number |
Provide the specific dollar amount of the second account you wish to liquidate.
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| Second Account Previous Employer Name | ||
| Second Account Previous Employer Name | Text |
Enter the name of the previous employer for the second account being moved.
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| Second Account Transaction Type | ||
| Second Account Transaction Type: Same Employer Plan with Fidelity | Checkbox |
Select this option if the second account transaction is with the same employer as your current plan with Fidelity.
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| Second Account Transaction Type: Previous Employer | Checkbox |
Select this option if the second account transaction involves an account from a previous employer.
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| Second Account Transaction Type: Rollover IRA | Checkbox |
Select this option if the second account transaction is for a Rollover IRA.
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| Second Account Transaction Type: Traditional IRA or SEP IRA | Checkbox |
Select this option if the second account transaction is for a Traditional IRA or SEP IRA.
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| Second Account Type | ||
| Second Account Type: 403(b) | Checkbox |
Check this box if the second account is a 403(b) type.
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| Second Account Type: Include Roth 403(b) balance | Checkbox |
Check this box if the second account includes a Roth 403(b) balance.
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| Second Account Type: 401(a)/(k) | Checkbox |
Check this box if the second account is a 401(a) or 401(k) type.
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| Second Account Type: Include Roth 401(k) balance | Checkbox |
Check this box if the second account includes a Roth 401(k) balance.
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| Second Account Type: 457(b) governmental | Checkbox |
Check this box if the second account is a 457(b) governmental type.
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| Second Account Type: Include Roth 457(b) governmental balance | Checkbox |
Check this box if the second account includes a Roth 457(b) governmental balance.
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| Second Account Type: IRA | Checkbox |
Check this box if the second account is an IRA type.
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| Second Account/Contract # | ||
| Second Account/Contract Number | Text |
Provide the account or contract number for the second account or contract.
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| Second Investment Instruction | ||
| Second Investment Fund Name | Text |
Enter the name of the second fund for investment.
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| Second Investment Fund Code | Text |
Enter the code for the second investment fund.
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| Second Investment Percentage | Number |
Enter the percentage of assets to be invested in this second fund.
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| Third Investment Instruction | ||
| Third Fund Name | Text |
Provide the name of the third investment fund.
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| Third Fund Code | Text |
Provide the fund code for the third investment fund.
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| Third Fund Percentage | Number |
Provide the percentage of assets to be invested in the third investment fund.
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| Transfer/Rollover/Exchange Form Checklist | ||
| Checklist 1: Include Account Statement | Checkbox |
Check this box to confirm that you have included your most recent account statement from your previous investment provider.
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| Checklist 2: Indicate Amount/Percentage | Checkbox |
Check this box to confirm that you have indicated the amount or percentage of money you are moving to Fidelity.
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| Checklist 3: Sign and Date Section 7 | Checkbox |
Check this box to confirm that you have signed and dated Section 7 of this form.
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| Checklist 4: Contact Previous Provider | Checkbox |
Check this box to confirm that you have contacted your previous provider to see if additional paperwork is required.
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| Checklist 5: Return Form Legibly | Checkbox |
Check this box to confirm that you have returned the completed form in a legible condition.
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