Fidelity NetBenefits Distribution—Rollover Form Completed Form Examples and Samples
Explore real-world filled examples of the Fidelity NetBenefits Distribution—Rollover Form. See sample completed forms for direct rollovers to Traditional IRAs, Roth IRAs, and other retirement accounts. Learn how to correctly fill out distribution type, withholding elections, rollover destination, and signature sections to avoid tax penalties and processing delays.
Fidelity NetBenefits Distribution—Rollover Form Example – Direct Rollover to Traditional IRA
How this form was filled:
A departing employee requests a direct rollover of their entire 401(k) balance to a Traditional IRA held at Fidelity. The form includes the participant's personal details, employer plan information, rollover destination account, withholding elections, and a dated signature. No taxes are withheld on a direct rollover, preserving the full value of the retirement savings.
Information used to fill out the document:
- Participant First Name: Michael
- Participant Middle Initial: J
- Participant Last Name: Harrington
- Social Security Number: XXX-XX-4782
- Date of Birth: 03/14/1978
- Daytime Phone Number: (614) 555-0192
- Email Address: [email protected]
- Mailing Address: 4821 Ridgewood Drive, Columbus, OH 43215
- Employer / Plan Name: Cornerstone Manufacturing Inc. 401(k) Savings Plan
- Plan Number: 72441
- Last Day of Employment: 12/31/2025
- Reason for Distribution: Separation from Service
- Distribution Type: Direct Rollover – Full Account Balance
- Rollover Destination Account Type: Traditional IRA
- Receiving Institution: Fidelity Investments
- Destination IRA Account Number: Z48-391027
- Federal Income Tax Withholding: 0% (No withholding – Direct Rollover)
- State Income Tax Withholding: 0% (No withholding – Direct Rollover)
- Estimated Account Balance at Time of Request: $84,350.00
- Vested Balance: $84,350.00
- Participant Signature: Michael J. Harrington
- Date Signed: 01/15/2026
What this filled form sample shows:
- Correctly selected Direct Rollover as the distribution type, avoiding mandatory 20% federal tax withholding
- Full account balance of $84,350.00 rolled over, preserving all tax-deferred growth
- Separation from Service listed as the qualifying reason for distribution after leaving Cornerstone Manufacturing Inc.
- Destination account properly identified as a Fidelity Traditional IRA with account number Z48-391027
- Zero federal and state withholding elected, which is appropriate and advantageous for a direct rollover
- Participant's date of birth and Social Security Number included to verify identity and plan eligibility
- Form signed and dated January 15, 2026, shortly after the December 31, 2025 separation date
- All required contact information (phone, email, mailing address) completed for processing follow-up
Form specifications and details:
| Use Case: | Direct rollover of full 401(k) balance to a Traditional IRA upon separation from service |
| Form Name: | Fidelity NetBenefits Distribution—Rollover Form |
| Distribution Reason: | Separation from Service |
| Rollover Type: | Direct Rollover (Trustee-to-Trustee Transfer) |
| Source Account Type: | 401(k) Savings Plan |
| Destination Account Type: | Traditional IRA |
| Tax Withholding: | None (0%) – standard for direct rollovers |
| Applicable Tax Year: | 2026 |
| Participant Age at Distribution: | 47 |
| Early Withdrawal Penalty Applies: | No – direct rollover is not a taxable distribution |
| Form Completion Date: | January 15, 2026 |
Created: February 25, 2026 04:43 AM
