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.
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 |
Created: February 25, 2026 06:01 AM
