This form contains 38 fields organized into 11 sections. Below is a complete list of every field, its type, and what information is expected.

Field Name	Type	Description
Account Owner Information
Account Owner Name	Text	Enter the full name of the account owner or participant.
Account Owner Social Security or Taxpayer ID Number	Text	Enter the Social Security Number or Taxpayer ID Number for the account owner. Max length: 10 characters
Account Owner Date of Birth	Date	Enter the date of birth for the account owner. Max length: 10 characters
Account Owner Evening Phone	Text	Enter the account owner's evening phone number where they can be reached. Max length: 10 characters
Account Owner Daytime Phone	Text	Enter the account owner's daytime phone number where they can be reached. Max length: 10 characters
After-Tax Contribution Distribution Options
Rollover to an IRA at Fidelity	Radiobutton	Check this box if you want to roll over your after-tax contributions to an IRA at Fidelity.
Rollover to an IRA with a different custodian	Radiobutton	Check this box if you want to roll over your after-tax contributions to an IRA managed by a different custodian.
Send check directly as non-rollover distribution	Radiobutton	Check this box if you want to receive your after-tax contributions directly as a non-rollover distribution.
IRA at Fidelity Account Number	Text	Enter the account number for the IRA at Fidelity to which after-tax contributions will be rolled over. Max length: 9 characters
Different IRA Custodian Name	Text	Enter the name of the IRA custodian to whom the check for after-tax contributions will be made payable.
Destination Plan for Rollover
Destination Plan Name	Text	Provide the full name of the employer's plan that will receive the rollover funds.
Destination Plan Number	Text	Enter the unique identification number for the employer's plan that will receive the rollover funds. Max length: 5 characters
General
Enter representative signature	Signature
Enter spouse's signature	Signature
Enter Notary or Plan Representative Signature	Signature
Enter participant signature	Signature
Marital Status
Married	Radiobutton	Check this box if you are currently married.
Not married	Radiobutton	Check this box if you are not currently married.
Notarization Details
Notary State	Text	Enter the name of the state where the notarization is being performed.
Notary County	Text	Enter the name of the county where the notarization is being performed.
Identification Type	Text	Enter the type of identification presented by the individual for verification.
Notarization Date	Date	Provide the date the notarization occurred. Max length: 10 characters
Printed Notary/Representative Name	Text	Enter the printed full name of the Notary Public or Plan Representative.
Notary/Representative Signature Date	Date	Provide the date the Notary Public or Plan Representative signed. Max length: 10 characters
Notary Commission Expiration Date	Date	Provide the expiration date of the Notary Public's commission. Max length: 2 characters
Participant Signature
Participant Name	Text	Enter the full name of the participant.
Participant Signature Date	Date	Enter the date the participant signed the form. Max length: 10 characters
Plan Sponsor Verification
Plan Representative Name (Printed)	Text	Enter the printed name of the authorized representative of the 'INTO' plan sponsor.
Plan Sponsor Verification Date	Date	Enter the date the plan sponsor verification was completed.
Roth Account Distribution Options
Roth Account Rollover to Fidelity Roth IRA	Radiobutton	Check this box if you want to roll over your Roth account distribution to a Roth IRA at Fidelity.
Roth Account Rollover to Different Custodian Roth IRA	Radiobutton	Check this box if you want to roll over your Roth account distribution to a Roth IRA with a different custodian.
Roth Account Non-Rollover Direct Distribution	Radiobutton	Check this box if you wish to receive your Roth account funds directly as a non-rollover distribution, acknowledging potential tax implications.
Roth Account Fidelity IRA Account Number	Text	Enter the account number for the Roth IRA at Fidelity to which the funds will be rolled over. Max length: 9 characters
Roth Account Different Custodian IRA Custodian	Text	Enter the name of the IRA Custodian for the Roth IRA when rolling over to a different custodian.
Source Plan for Rollover
Source Plan Employer Name	Text	Enter the name of the employer plan from which the rollover will originate.
Source Plan Number	Text	Enter the plan number of the employer plan from which the rollover will originate. Max length: 5 characters
Spouse's Consent
Printed Spouse Name	Text	Enter the full printed name of the spouse providing consent.
Spouse's Signature Date	Date	Enter the date the spouse signed the consent form. Max length: 10 characters

Plan-to-Plan Direct Rollover Form - Fidelity NetBenefits Instructions