Special Tax Notice: Your Rollover Options - Fidelity Investments Completed Form Examples and Samples

Explore a filled example of the Special Tax Notice: Your Rollover Options form from Fidelity Investments. See a real-world sample completed by a 401(k) plan participant electing a direct rollover to a Traditional IRA, with detailed explanations of tax withholding rules, the 60-day rollover deadline, mandatory 20% withholding, and early distribution penalties. Perfect for plan participants, HR administrators, and financial advisors seeking guidance on how to correctly complete this Fidelity rollover notice.
Fill out form with AI
Download PDF Example
Completed Special Tax Notice Your Rollover Options form for a Fidelity Investments participant rolling over a 401(k) distribution to a Traditional IRA

Special Tax Notice: Your Rollover Options – Fidelity Investments Example

How this form was filled:

This example shows a Fidelity Investments plan participant, Sarah M. Thompson, who is separating from her employer and electing a direct rollover of her entire 401(k) balance to a Traditional IRA. The notice acknowledges her understanding of the tax withholding rules, the 60-day rollover deadline, and the available rollover options, including direct rollover to an eligible retirement plan and the 20% mandatory withholding that applies to non-direct distributions.

Information used to fill out the document:

  • Participant Full Name: Sarah M. Thompson
  • Participant Date of Birth: March 14, 1978
  • Participant Social Security Number (last 4 digits): XXXX-XX-7842
  • Employer / Plan Sponsor Name: Greenfield Technologies Inc.
  • Plan Name: Greenfield Technologies 401(k) Retirement Savings Plan
  • Plan Number: GTI-401K-0047
  • Fidelity Account Number: X84-729301
  • Distribution Reason: Separation from Service
  • Distribution Date: January 31, 2026
  • Total Eligible Rollover Amount: $142,500.00
  • Pre-Tax (Traditional) Contribution Balance: $128,750.00
  • After-Tax (Roth) Contribution Balance: $13,750.00
  • Rollover Election: Direct Rollover – 100% of eligible rollover distribution
  • Rollover Destination Account Type: Traditional IRA
  • Rollover Destination Institution: Fidelity Investments
  • Rollover Destination Account Number: X22-984512
  • Federal Income Tax Withholding Election: Waived – Direct Rollover elected (0% withheld)
  • State Income Tax Withholding: Not applicable – Direct Rollover elected
  • Participant State of Residence: Texas (no state income tax)
  • 20% Mandatory Withholding Acknowledged: Yes – Participant acknowledges 20% withholding applies to non-direct distributions
  • 60-Day Rollover Rule Acknowledged: Yes – Participant acknowledges the 60-day deadline for indirect rollovers
  • Early Distribution Penalty Acknowledgment: Participant confirms age 47 – 10% early distribution penalty may apply to non-rolled amounts
  • Special Tax Treatment Acknowledgment (NUA): Not applicable – No employer securities in distribution
  • Special Tax Treatment Acknowledgment (10-Year Averaging): Not applicable – Participant born after 1936
  • Participant Signature: Sarah M. Thompson
  • Date Signed: January 15, 2026
  • Plan Administrator Name: Robert J. Callahan
  • Plan Administrator Title: Director of Human Resources
  • Plan Administrator Signature Date: January 16, 2026

What this filled form sample shows:

  • Illustrates a direct rollover election from a traditional 401(k) to a Fidelity Traditional IRA, avoiding mandatory 20% federal withholding
  • Demonstrates proper acknowledgment of the 20% mandatory withholding rule that applies when a participant receives a distribution directly instead of electing a direct rollover
  • Shows correct handling of a plan with both pre-tax and after-tax (Roth) contribution balances totaling $142,500
  • Highlights the 60-day rollover deadline rule and participant's written acknowledgment of the indirect rollover window
  • Covers the 10% early distribution penalty disclosure relevant to a participant under age 59½ (age 47)
  • Confirms no state income tax withholding is required due to Texas residency, with proper notation on the form
  • Reflects a separation-from-service distribution scenario, one of the most common triggers for rollover notices
  • Includes plan administrator co-acknowledgment with signature and date, validating the notice was properly delivered

Form specifications and details:

Use Case: Separation from service – direct rollover of full 401(k) balance to Traditional IRA
Form Type: Special Tax Notice: Your Rollover Options (Fidelity Investments)
Governing Law: IRC §402(f) – Required Rollover Notice
Applicable Plan Type: 401(k) Defined Contribution Plan
Distribution Type: Eligible Rollover Distribution
Rollover Type: Direct Rollover (trustee-to-trustee transfer)
Federal Withholding Rate on Direct Rollover: 0% (waived via direct rollover election)
Federal Withholding Rate if No Election: 20% mandatory
Early Withdrawal Penalty Rate (if applicable): 10% on taxable amounts not rolled over
Notice Delivery Requirement: Must be provided no fewer than 30 days and no more than 180 days before distribution
Participant Right to Waive 30-Day Period: Yes – participant may waive the 30-day waiting period
Eligible Rollover Destination Options: Traditional IRA, Roth IRA (with tax consequences), 401(k), 403(b), 457(b) governmental plan
Roth Conversion Option: Available but would trigger ordinary income tax on pre-tax amounts
Net Unrealized Appreciation (NUA) Applicable: No – no employer securities in distribution
10-Year Forward Averaging Applicable: No – participant born after January 1, 1936
State Tax Withholding Requirement: None – Texas has no state income tax
Form Completion Year: 2026
Categories: investment forms, rollover forms, Fidelity forms
Created: February 25, 2026 06:01 AM
Completed Special Tax Notice Your Rollover Options form for a Fidelity Investments participant rolling over a 401(k) distribution to a Traditional IRA