Fidelity Investments Transfer/Rollover/Exchange Form Instructions
This form contains 90 fields organized into 20 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Employer Information | ||
| Still Employed - Yes | Radiobutton |
Check this box if you are still employed with the employer sponsoring your Fidelity Retirement Account.
|
| Still Employed - No | Radiobutton |
Check this box if you are no longer employed with the employer sponsoring your Fidelity Retirement Account.
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| Employer Sponsoring Fidelity Retirement Account | Text |
Provide the full name of the employer sponsoring your Fidelity retirement account as it appears on your Fidelity statement or enrollment paperwork.
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| Employer City and State | Text |
Enter the city and state of the employer sponsoring your Fidelity retirement account.
|
| Employer Plan Acceptance | ||
| Employer Authorized Signature | Text |
Provide the authorized signature of the employer.
|
| Employer Authorized Signature Date | Date |
Enter the date the employer's authorized signature was provided.
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| Employer Authorized Printed Name | Text |
Provide the printed name of the authorized employer.
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| Fidelity Account Information for 3A | ||
| 403(b | CheckBox | |
| 3A 401(a)/(k) | Checkbox |
Check this box if your Fidelity retirement account for section 3A is a 401(a) or 401(k) plan type.
|
| 3A 457(b) Governmental | Checkbox |
Check this box if your Fidelity retirement account for section 3A is a 457(b) governmental plan type.
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| Fidelity 3A Plan Number | Text |
Enter the plan number for Fidelity Account 3A if known.
|
| Fidelity Account Information for 3B | ||
| 3B 403(b) | Checkbox |
Check this box if the Fidelity Account Plan Type for 3B is a 403(b) plan.
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| 3B 401(a)/(k) | Checkbox |
Check this box if the Fidelity Account Plan Type for 3B is a 401(a)/(k) plan.
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| 3B 457(b) governmental | Checkbox |
Check this box if the Fidelity Account Plan Type for 3B is a 457(b) governmental plan.
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| 3B Plan Number | Text |
Enter the plan number associated with Fidelity Account Information 3B.
|
| Fifth Investment Allocation Percentage | ||
| Fifth Investment Allocation Percentage | Number |
Enter the fifth investment allocation percentage.
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| First Account Liquidation Amount | ||
| First Account Full Liquidation | Checkbox |
Check this box to indicate that the first account should be fully liquidated (100% of the balance).
|
| First Account Partial Liquidation | Checkbox |
Check this box to indicate that only a portion of the first account should be liquidated.
|
| First Account Liquidation Percentage | Number |
Enter the percentage of the first account to be liquidated.
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| First Account Liquidation Dollar Amount | Number |
Enter the specific dollar amount of the first account to be liquidated.
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| First Account Transaction Details | ||
| The Same Employer as My Employer Plan with Fidelity | CheckBox | |
| First Account Transaction - Previous Employer | Checkbox |
Check this box if the transaction for the first account is from a previous employer.
|
| First Account Transaction - Rollover IRA | Checkbox |
Check this box if the transaction for the first account is for a Rollover IRA.
|
| First Account Transaction - Traditional IRA or SEP IRA | Checkbox |
Check this box if the transaction for the first account is for a Traditional IRA or a SEP IRA.
|
| First Account Previous Employer Name | Text |
Enter the name of the previous employer for the first account transaction.
|
| First Account/Contract Information | ||
| First Account 403(b) | Checkbox |
Check this box if the first account/contract you are moving is a 403(b) type.
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| First Account Include Roth 403(b) Balance | Checkbox |
Check this box if you want to include the Roth 403(b) balance for the first account/contract.
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| First Account 401(a)/(k) | Checkbox |
Check this box if the first account/contract you are moving is a 401(a) or 401(k) type.
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| First Account Include Roth 401(k) Balance | Checkbox |
Check this box if you want to include the Roth 401(k) balance for the first account/contract.
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| First Account 457(b) Governmental | Checkbox |
Check this box if the first account/contract you are moving is a 457(b) governmental type.
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| First Account Include Roth 457(b) Governmental Balance | Checkbox |
Check this box if you want to include the Roth 457(b) governmental balance for the first account/contract.
|
| First Account IRA | Checkbox |
Check this box if the first account/contract you are moving is an IRA type.
|
| First Account/Contract Number | Text |
Provide the account or contract number for the first account or contract you wish to move.
|
| First Investment Allocation | ||
| First Investment Fund Name | Text |
Provide the name of the first investment fund.
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| First Investment Fund Code | Text |
Provide the code for the first investment fund.
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| First Investment Percentage | Number |
Enter the percentage of assets to be allocated to the first investment fund.
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| Form Checklist | ||
| Form Checklist Item 1: Include Account Statement | Checkbox |
Check this box if you have included your most recent account statement from your previous investment provider.
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| Form Checklist Item 2: Indicate Amount/Percentage | Checkbox |
Check this box if you have indicated the amount or percentage of money you are moving to Fidelity.
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| Form Checklist Item 3: Sign and Date Section 7 | Checkbox |
Check this box if you have signed and dated Section 7 of this form.
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| Form Checklist Item 4: Contact Previous Provider for Paperwork | Checkbox |
Check this box if you have contacted your previous provider to see if additional paperwork is required.
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| Form Checklist Item 5: Return Legible Form | Checkbox |
Check this box if you have returned the completed form in a legible condition.
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| Fourth Investment Allocation | ||
| Fourth Investment Fund Name | Text |
Enter the name of the fourth investment fund.
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| Fourth Investment Fund Code | Text |
Enter the code for the fourth investment fund.
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| Fourth Investment Percentage | Number |
Enter the percentage of the total investment to allocate to this fund.
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| Investment Provider Information | ||
| Investment Provider Name | Text |
Enter the name of the investment provider from which you are moving money.
|
| Provider Street Address | Text |
Enter the street address of the investment provider.
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| Provider City | Text |
Enter the city of the investment provider.
|
| Provider State | Text |
Enter the state of the investment provider.
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| Provider ZIP Code | Text |
Enter the ZIP code of the investment provider.
|
| Provider Phone Number | Text |
Enter the main phone number for the investment provider.
|
| Provider Phone Extension | Text |
Enter the extension, if any, for the investment provider's phone number.
|
| Investment Selection Preference | ||
| Yes | Checkbox |
Check this box if you would like the assets to be invested in your current investment selection.
|
| No | Checkbox |
Check this box if you would not like the assets to be invested in your current investment selection, and you will specify new instructions below.
|
| Page 6 | ||
| Your Signature | Text |
Provide your signature as a text entry.
|
| Date | Date |
Enter the date of signing.
|
| Second Account Liquidation Amount | ||
| Full Liquidation/100 | CheckBox | |
| Second Account Partial Liquidation | Checkbox |
Check this box if you want to liquidate only a portion of the second account's assets.
|
| Second Account Liquidation Percentage | Number |
Enter the percentage of the second account to be liquidated.
|
| Second Account Liquidation Amount | Number |
Enter the dollar amount of the second account to be liquidated.
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| Second Account Transaction Details | ||
| Second Account - Same Employer Plan | Checkbox |
Check this box if the transaction for the second account involves moving funds from the same employer's plan with Fidelity.
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| Second Account - Previous Employer | Checkbox |
Check this box if the transaction for the second account involves moving funds from a previous employer's account.
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| Second Account - Rollover IRA | Checkbox |
Check this box if the transaction for the second account involves moving funds from a Rollover IRA.
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| Second Account - Traditional IRA or SEP IRA | Checkbox |
Check this box if the transaction for the second account involves moving funds from a Traditional IRA or SEP IRA.
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| Second Account Previous Employer Name | Text |
Provide the name of the previous employer associated with the second account transaction.
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| Second Account/Contract Information | ||
| Second Account 403(b) | Checkbox |
Check this box if the second account or contract you are moving is a 403(b) plan.
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| Second Account Include Roth 403(b) Balance | Checkbox |
Check this box if the second 403(b) account includes a Roth balance that you wish to move.
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| Second Account 401(a)/(k) | Checkbox |
Check this box if the second account or contract you are moving is a 401(a) or 401(k) plan.
|
| Second Account Include Roth 401(k) Balance | Checkbox |
Check this box if the second 401(k) account includes a Roth balance that you wish to move.
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| Second Account 457(b) Governmental | Checkbox |
Check this box if the second account or contract you are moving is a governmental 457(b) plan.
|
| Second Account Include Roth 457(b) Governmental Balance | Checkbox |
Check this box if the second governmental 457(b) account includes a Roth balance that you wish to move.
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| Second Account IRA | Checkbox |
Check this box if the second account or contract you are moving is an Individual Retirement Account (IRA).
|
| Second Account/Contract Number | Text |
Please enter the account or contract number for the second account or contract.
|
| Second Investment Allocation | ||
| Second Investment Fund Name | Text |
Enter the name of the second investment fund.
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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 allocated to the second investment.
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| Third Investment Allocation | ||
| Third Investment Fund Name | Text |
Enter the name of the third investment fund allocation.
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| Third Investment Fund Code | Text |
Enter the code for the third investment fund allocation.
|
| Third Investment Percentage | Number |
Enter the percentage of the third investment fund allocation.
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| Your Information | ||
| Middle Initial | Text |
Provide your middle initial.
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| State | Text |
Provide the state for your mailing address.
|
| Social Security Number or Tax ID | Text |
Provide your Social Security Number or Tax Identification Number.
|
| Date of Birth | Date |
Provide your date of birth.
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| First Name | Text |
Provide your first name.
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| Last Name | Text |
Provide your last name.
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| Mailing Address | Text |
Provide your complete mailing street address.
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| City | Text |
Provide the city for your mailing address.
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| ZIP Code | Text |
Provide your ZIP code.
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| Daytime Phone | Text |
Provide your daytime phone number.
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| Evening Phone | Text |
Provide your evening phone number.
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| Email Address | Text |
Provide your email address.
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