Fidelity Plan-to-Plan Direct Rollover Form Completed Form Examples and Samples

View clear, filled-out examples of the Fidelity Plan-to-Plan Direct Rollover Form. Our detailed samples guide you on how to complete the form correctly for a seamless 401(k) or retirement plan transfer.
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Completed Fidelity Plan-to-Plan Direct Rollover Form sample for moving a 401(k) to a new employer's plan.

Fidelity Plan-to-Plan Direct Rollover Form Example

How this form was filled:

This example shows a participant, Jane Smith, rolling over her entire vested 401(k) balance from her former employer's plan ('Innovate Corp') directly to her new employer's plan ('Future Solutions Inc.'). The form correctly identifies both the distributing and receiving plans, specifies a direct rollover of the full balance due to termination of employment, and includes the participant's signature and date.

Information used to fill out the document:

  • Participant Name: Jane A. Smith
  • Social Security Number (Last 4): 5678
  • Date of Birth: 06/15/1988
  • Mailing Address: 456 Oak Avenue, Anytown, CA 90210
  • Phone Number: (555) 123-4567
  • Former Employer (Distributing Plan): Innovate Corp
  • Distributing Plan Name: Innovate Corp 401(k) Plan
  • Distributing Plan Number: 12345
  • New Employer (Receiving Plan): Future Solutions Inc.
  • Receiving Plan Name: Future Solutions Inc. 401(k) Plan
  • Receiving Plan Number: 67890
  • Reason for Distribution: Termination of Employment
  • Rollover Amount: Entire vested account balance
  • Signature: Jane A. Smith
  • Date of Signature: 05/20/2026

What this filled form sample shows:

  • Clear identification of both the distributing (old) and receiving (new) plans, including plan numbers.
  • Specification of a direct rollover, which is a non-taxable event and avoids mandatory 20% tax withholding.
  • Indication to roll over the entire vested account balance for complete consolidation of funds.
  • Properly completed participant information and an authorized signature and date.

Form specifications and details:

Use Case: 401(k) rollover from a former employer to a new employer's plan, both administered by Fidelity.
Form Name: Fidelity Plan-to-Plan Direct Rollover Form
Action Type: Direct Rollover of Pre-tax and Roth funds
Triggering Event: Termination of Employment
Categories: rollover forms
Created: February 25, 2026 06:28 PM
Completed Fidelity Plan-to-Plan Direct Rollover Form sample for moving a 401(k) to a new employer's plan.