Plan-to-Plan Direct Rollover Form - Fidelity NetBenefits Completed Form Examples and Samples
View a completed Plan-to-Plan Direct Rollover Form example for Fidelity NetBenefits. See a real-world sample showing how to correctly fill out participant details, distributing plan information, receiving plan details, rollover amounts, and required signatures to complete a tax-free direct 401(k) rollover without penalties or mandatory withholding.
Plan-to-Plan Direct Rollover Form – Fidelity NetBenefits Example
How this form was filled:
This example shows a participant rolling over their entire 401(k) balance from a former employer's retirement plan directly into their current employer's Fidelity NetBenefits-administered 401(k) plan. The form includes participant details, distributing plan information, receiving plan information, rollover amount, and required signatures — demonstrating a correctly completed direct rollover to avoid taxes and penalties.
Information used to fill out the document:
- Participant Full Name: Michael R. Torres
- Participant Date of Birth: 03/14/1982
- Participant SSN (last 4 digits): 7291
- Participant Mailing Address: 4821 Willow Creek Drive, Austin, TX 78701
- Participant Phone Number: (512) 555-0194
- Participant Email Address: [email protected]
- Fidelity NetBenefits Account Number: Z12-845903
- Distributing Plan Name: Greenfield Manufacturing Inc. 401(k) Savings Plan
- Distributing Plan Administrator: Vanguard Retirement Services
- Distributing Plan Account Number: 4409-27731-GF
- Distributing Plan Address: 100 Vanguard Blvd, Malvern, PA 19355
- Distributing Plan Phone Number: (800) 523-1188
- Receiving Plan Name: Horizon Tech Solutions LLC 401(k) Plan
- Receiving Plan Fidelity Plan Number: 73845
- Receiving Employer Name: Horizon Tech Solutions LLC
- Type of Rollover Contribution: Pre-Tax (Traditional) 401(k)
- Rollover Amount: Full / Entire Account Balance
- Estimated Rollover Amount: $48,250.00
- Investment Election for Rollover: Same as current deferral investment elections on file
- Rollover Source: Former Employer Qualified Plan (401k)
- Check Payable To: Fidelity Investments Institutional Operations Co. FBO Michael R. Torres
- Participant Signature: Michael R. Torres
- Date Signed: 01/15/2026
- Employer/Plan Sponsor Signature: Sandra L. Whitfield (HR Director, Horizon Tech Solutions LLC)
- Employer Signature Date: 01/17/2026
What this filled form sample shows:
- Correctly identified participant information including SSN last 4 digits, date of birth, and Fidelity NetBenefits account number
- Fully completed distributing plan section with former employer plan name, administrator (Vanguard), plan account number, and contact details
- Accurately filled receiving plan section with current employer's Fidelity plan number and plan name
- Selected pre-tax (Traditional) 401(k) as the rollover contribution type to ensure proper tax treatment
- Specified full account balance rollover of $48,250.00 to consolidate all retirement savings
- Check made payable to Fidelity Investments Institutional Operations Co. FBO participant to qualify as a direct rollover and avoid 20% mandatory withholding
- Investment elections defaulted to existing deferral elections on file for seamless reinvestment
- Properly signed and dated by both the participant (01/15/2026) and the plan sponsor/HR representative (01/17/2026)
Form specifications and details:
| Use Case: | Full pre-tax 401(k) balance rollover from former employer plan to current employer Fidelity NetBenefits plan |
| Form Name: | Plan-to-Plan Direct Rollover Form |
| Platform: | Fidelity NetBenefits |
| Rollover Type: | Direct Rollover (Trustee-to-Trustee Transfer) |
| Contribution Source: | Pre-Tax / Traditional 401(k) |
| Rollover Scope: | Full Account Balance |
| Distributing Plan Administrator: | Vanguard Retirement Services |
| Receiving Plan Administrator: | Fidelity Investments |
| Tax Withholding: | None (Direct Rollover qualifies for 0% withholding) |
| IRS Form Generated: | Form 1099-R (coded as direct rollover, Box 7 Code G) |
| Eligible Plan Types: | 401(k) to 401(k) |
| Signature Requirements: | Participant signature and Plan Sponsor/Employer authorization required |
| Processing Time: | Typically 3–5 business days after distributing plan releases funds |
| Date Completed: | January 15, 2026 |
Created: February 25, 2026 05:50 AM
