Fidelity NetBenefits Plan-to-Plan Direct Rollover Form Completed Form Examples and Samples
Explore real-world filled examples of the Fidelity NetBenefits Plan-to-Plan Direct Rollover Form. See sample forms with completed participant information, distributing and receiving plan details, rollover amounts, and signatures. Perfect for anyone looking to understand how to correctly fill out a Fidelity NetBenefits Plan-to-Plan Direct Rollover Form for 401(k) transfers between employers.
Fidelity NetBenefits Plan-to-Plan Direct Rollover Form Example – 401(k) to New Employer's 401(k)
How this form was filled:
This example shows how a participant completes the Fidelity NetBenefits Plan-to-Plan Direct Rollover Form to transfer their entire 401(k) balance from a former employer's Fidelity-administered plan directly into their new employer's Fidelity NetBenefits 401(k) plan. The form includes the participant's personal information, both the distributing and receiving plan details, rollover amount selection, and a wet signature with date.
Information used to fill out the document:
- Participant Full Name: Michael R. Torres
- Social Security Number (SSN): XXX-XX-4782
- Date of Birth: 03/14/1985
- Daytime Phone Number: (614) 555-0193
- Email Address: [email protected]
- Mailing Address: 4821 Birchwood Drive, Columbus, OH 43215
- Distributing Plan Name (Former Employer): Apex Manufacturing Inc. 401(k) Savings Plan
- Distributing Plan Account Number: 726-448801
- Distributing Plan Employer: Apex Manufacturing Inc.
- Receiving Plan Name (New Employer): Crestview Technology Solutions 401(k) Plan
- Receiving Plan Account Number: 839-557294
- Receiving Plan Employer: Crestview Technology Solutions
- Rollover Type: Full Rollover – Entire Vested Account Balance
- Asset Type: Pre-Tax (Traditional) 401(k) Contributions
- Rollover Amount: $87,450.22
- Roth Contributions Included: No
- Outstanding Loan Balance: None
- Reason for Distribution: Separation from Service
- Signature: Michael R. Torres
- Date Signed: 02/11/2026
What this filled form sample shows:
- Full participant identification including SSN (masked), date of birth, and contact information
- Clearly identified distributing plan (former employer Apex Manufacturing Inc.) with account number
- Clearly identified receiving plan (new employer Crestview Technology Solutions) with account number
- Selection of a full pre-tax rollover of the entire vested account balance of $87,450.22
- Confirmation that no Roth after-tax assets or outstanding loan balances are included
- Reason for distribution correctly noted as Separation from Service
- Properly signed and dated authorization section dated 02/11/2026
Form specifications and details:
| Use Case: | Direct plan-to-plan rollover of a full 401(k) balance after changing employers |
| Form Name: | Fidelity NetBenefits Plan-to-Plan Direct Rollover Form |
| Plan Type: | 401(k) to 401(k) |
| Rollover Method: | Direct Rollover (no taxes withheld) |
| Distributing Institution: | Fidelity NetBenefits |
| Receiving Institution: | Fidelity NetBenefits |
| Rollover Scope: | Full vested account balance |
| Pre-Tax vs. Roth: | Pre-Tax only |
| Triggering Event: | Separation from Service (job change) |
| Outstanding Loans: | None |
| Tax Withholding: | Not applicable – direct rollover |
| Penalty Risk: | None – qualifies as a direct rollover |
| Applicable Year: | 2026 |
Created: February 25, 2026 04:42 AM
