Participant Information – All Information is Required
Participant Name _________________________________ Email Address_________________________
Company Name _____________________________________ Phone Number _____________________
Date of Birth _____/_______/_______ Date of Hire _____/______/_______ SSN: XXX-XX-___________
Important: Does your rollover contain Roth Contributions? ☐ Yes ☐ No
If no, skip to Investment Selection Information, then review and sign the remainder of the form.
If yes, complete all information below. Your Roth rollover cannot be processed without this information.
Establishment Date (date of first Roth deferral) ______/______/________
Roth Contribution Amount $_________ plus Roth Earnings Amount $__________ equals Total Check Amount $___________
Note: Only plans that permit employees to make Roth 401(k) salary deferrals may accept Roth 401(k) rollovers. Refer to the General Information Sheet/Summary Plan
Description or contact your plan administrator to determine if your plan accepts Roth 401(k) rollovers.
Investment Selection Information
• If you have made investments selections in your company’s 401(k) retirement plan with Paychex, your rollover funds will be invested
according to your current fund allocations.
• If you have not made investment selections and are currently eligible to participate in your company’s plan, select funds by accessing the
Paychex 401(k) participant website at http://www.paychexflex.com.
• If you have not made investment selections prior to your rollover being processed, your funds will be invested in the Participant Default
Fund within your company’s plan.
Important Information Regarding your Rollover
• Receipt of this form by Paychex does not initiate the rollover of prior plan assets. You must contact your prior plan administrator to
initiate the transfer of assets to Paychex.
• If you are not yet eligible to participate in your company’s plan, you may roll funds into the plan. However, a loan from the rollover
balance is not available until you are eligible to participate in the plan.
• Funds rolled into the plan become subject to the terms of the plan sponsored by your employer.
• Your rollover check must be payable to “Paychex FBO Participant Name/Social Security Number.”
Authorization
I hereby certify that this rollover represents a distribution from a qualified retirement plan, and that I understand the terms of the plan as they
apply to my rollover account. The authorization set forth in this form shall become effective at the earliest time permitted by the terms of the plan.
I acknowledge that I have received and reviewed the Fee Disclosure Statement for Participants.
Participant Signature ________________________________________________ Date _______/_________/__________
Email this form to
ClientSupport_Paperwork@paychex.com
Paychex Retirement Services
P.O. Box 26787
New York, NY 10087-6787
Attn: Client Support 585-389-7878
Employee Rollover Form
Electronic signatures cannot be accepted
