Fidelity Plan-to-Plan Direct Rollover Form Instructions
This form contains 45 fields organized into 15 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Account Owner Personal Information | ||
| Account Owner Name | Text |
Please provide the full legal name of the account owner.
|
| Account Owner Social Security or Taxpayer ID Number | Text |
Please provide the Social Security number or Taxpayer ID number for the account owner.
|
| Account Owner Date of Birth | Date |
Please provide the date of birth for the account owner.
|
| After-Tax Contribution Option | ||
| Send a check directly to me as a non-rollover distribution | Checkbox |
Check this box if you want your after-tax contributions (excluding earnings) to be sent directly to you as a non-rollover distribution.
|
| Contact Information | ||
| Evening Phone | Text |
Provide a valid evening phone number where you can be reached for questions regarding this request.
|
| Daytime Phone | Text |
Provide a valid daytime phone number where you can be reached for questions regarding this request.
|
| General | ||
| Signature1 | Signature | |
| Signature4 | Signature | |
| Signature3 | Signature | |
| 3Date.0 | Text | |
| 3Date.1 | Text | |
| 3Date.2 | Text | |
| 3Date.3 | Text | |
| 3Date.4 | Text | |
| 3Date.5 | Text | |
| 3Date.6 | Text | |
| 3Date.7 | Text | |
| Signature9 | Signature | |
| Marital Status | ||
| Married | Checkbox |
Check this box if you are currently married. Your spouse may need to sign this form.
|
| Not married | Checkbox |
Check this box if you are not currently married.
|
| Notarization Statement | ||
| Notarization Day | Text |
Enter the day of the month when the notarization occurred.
|
| Notarization Month | Text |
Enter the month when the notarization occurred.
|
| Notarization Year | Text |
Enter the year when the notarization occurred.
|
| Person Appearing Before Notary | Text |
Enter the full name of the person who appeared before the notary or plan representative.
|
| Notary/Plan Representative Details | ||
| Notary/Plan Representative Name | Text |
Enter the name of the notary public or plan representative.
|
| Notary Commission Expiration Date | Date |
Provide the expiration date of the notary's commission.
|
| Commissioned in State | Text |
Enter the state in which the notary's commission was issued.
|
| Notary/Plan Representative Signature Date | Date |
Enter the date when the notary public or plan representative signed the form.
|
| Participant Acknowledgement | ||
| Participant Name | Text |
Enter the full printed name of the participant.
|
| Acknowledgement Date | Date |
Enter the date the participant acknowledges the form.
|
| Plan Sponsor Verification | ||
| Vesting Percentage | Number |
Enter the vesting percentage applicable to the plan sponsor.
|
| Termination Date | Date |
Provide the date the plan sponsor's participation was terminated.
|
| Plan Representative Name | Text |
Enter the printed full name of the authorized representative of the employer.
|
| Representative Signature Date | Date |
Provide the date the representative signed the form.
|
| Rollover Destination Plan | ||
| Destination Employer Plan Name | Text |
Enter the name of the employer plan where the rollover funds will be deposited.
|
| Destination Plan Number | Text |
Enter the plan number for the destination employer plan.
|
| Rollover Source Plan | ||
| Source Plan Name | Text |
Enter the full name of the employer plan from which the funds are being rolled over.
|
| Source Plan Number | Text |
Enter the identifying number for the employer plan from which the funds are being rolled over.
|
| Roth Account Non-Rollover Distribution Option | ||
| Roth Account Non-Rollover Distribution | Checkbox |
Check this box if you want a non-rollover distribution from your Roth Account to be sent directly to you.
|
| Roth IRA Rollover to Different Custodian | ||
| Rollover to a Roth IRA with a different custodian | Checkbox |
Check this box if you wish to roll over your Roth IRA funds to an account held by a different custodian or financial institution.
|
| IRA Custodian Name | Text |
Provide the name of the IRA Custodian to whom the check will be made payable.
|
| Roth IRA Rollover to Fidelity | ||
| Fidelity Roth IRA Account Number | Text |
Enter the account number for the Roth IRA at Fidelity to which the rollover will be made.
|
| Rollover to a Roth IRA at Fidelity | CheckBox | |
| Spouse's Consent | ||
| Spouse's Printed Name | Text |
Enter the full printed name of the spouse providing consent.
|
| Spouse's Consent Date | Date |
Enter the date the spouse signed this consent.
|