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

Explore clear examples and samples of a filled Plan-to-Plan Direct Rollover Form. Learn how to correctly complete the paperwork to transfer your 401(k) or other retirement funds directly to a new plan, ensuring a smooth, tax-free process. Our detailed guides help you avoid common mistakes.
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A filled-out Plan-to-Plan Direct Rollover Form sample showing a 401(k) transfer from a previous employer to a new one.

Plan-to-Plan Direct Rollover Form Example - 401(k) to 401(k)

How this form was filled:

This example shows how to complete a Plan-to-Plan Direct Rollover form to move 401(k) funds. The participant, Jane Smith, is transferring her entire vested balance from her old employer's plan (Innovate Corp. 401(k) Plan) directly to her new employer's retirement plan (Global Solutions Inc. Retirement Savings Plan).

Information used to fill out the document:

  • Participant Name: Jane Marie Smith
  • Social Security Number: XXX-XX-1234
  • Address: 456 Oak Avenue, Anytown, USA 54321
  • Date of Birth: 05/20/1990
  • Distributing Plan Name: Innovate Corp. 401(k) Plan
  • Distributing Plan Administrator: BrightFuture Financial
  • Distributing Plan Account #: IC-987654321
  • Receiving Plan Name: Global Solutions Inc. Retirement Savings Plan
  • Receiving Plan Administrator: Future Wealth Partners
  • Receiving Plan Account #: GS-12345-6789
  • Rollover Amount: 100% of Vested Account Balance
  • Rollover Type: Direct Rollover (Pre-tax funds)
  • Signature: Jane M. Smith
  • Date: 07/15/2026

What this filled form sample shows:

  • Clear identification of both the distributing (old) plan and the receiving (new) plan, including administrator and account details.
  • Explicit instruction for a direct rollover, ensuring funds are sent directly to the new plan to avoid mandatory 20% tax withholding.
  • Complete and accurate participant information, which is crucial for correct processing.
  • Proper authorization via a valid participant signature and date to execute the transfer.

Form specifications and details:

Use Case: Transferring 401(k) funds from a former employer's plan to a new employer's plan.
Form Type: Plan-to-Plan Direct Rollover Request Form
Categories: rollover forms
Created: February 25, 2026 06:34 PM
A filled-out Plan-to-Plan Direct Rollover Form sample showing a 401(k) transfer from a previous employer to a new one.