Fillable Transfer/Rollover/Exchange Form Instructions (Fidelity Investments)

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Transfer/Rollover/Exchange Form Instructions (Fidelity Investments)

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Transfer/Rollover/Exchange Form
Instructions
Reference the instructions below while completing the form. For additional assistance, please contact Fidelity Investments at
1-800-343-0860 or, for the hearing impaired, dial 711, Monday through Friday, 8 a.m. to midnight Eastern time (excluding
New York Stock Exchange holidays, except Good Friday).
1. YOUR INFORMATION
Please provide your information in this section.
2. INVESTMENT PROVIDER YOU ARE MOVING MONEY FROM
Please review your most recent statement for this name and address, and include a copy of the statement with this form. Please contact
your previous investment provider to see if additional paperwork is required.
3. ACCOUNT(S) OR CONTRACT(S) TO MOVE
Account or Contract Number: This number is available on your previous investment provider account statement. If you are
unable to locate this number on your statement, please contact the investment provider. If you do not provide an account or contract
number, we will use your Social Security number or U.S. Tax Identification number to request the assets to be moved.
Type of Account or Contract: If you are unsure of the type of account or contract, please contact the Previous Investment Provider
or refer to your statement. Select at least one.
The Account or Contract Number is from: Please see the descriptions below that relate to each of the four transactions. If you
choose “A Previous Employer,” provide the name of that employer.
The Same Employer as My Employer Plan with Fidelity. Movement of assets from 403(b) to 403(b) will be requested as a
vendor or contract exchange. Movement of money between the same plan types, excluding 403(b) plans [401(a) to 401(a), 401(k)
to 401(k), 457(b) to 457(b)], will be requested as an in-plan transfer. Movement of money between different plan types will be
requested as a rollover.
A Previous Employer. For 403(b) and 401(a)/(k) plans, this is a rollover transaction. For governmental 457(b) plans, this is a
rollover unless Fidelity receives direction to process as a transfer.
A Rollover IRA. This is a rollover transaction. After-tax value may not be rolled from an IRA.
A Traditional IRA or SEP IRA. This is a rollover transaction. Roth IRAs and Coverdell IRAs cannot be accepted.
Liquidation Amount: Specify the amount of money you want moved to your Fidelity account. If you choose “Full Liquidation/100%,”
Fidelity will request your full balance. If you choose “Partial Liquidation,” Fidelity will request the dollar amount or percentage you
specify.
If you do not specify an amount, Fidelity will move/liquidate 100%. If you are moving 457(b) assets, please be aware that
governmental 457(b) assets must be moved into a governmental 457(b) plan, and nongovernmental 457(b) assets must be moved into
a nongovernmental 457(b) plan. Transfers from nongovernmental 457(b) plans are not provided for on this form. Talk with your plan
sponsor or call Fidelity to discuss transfers from nongovernmental 457(b) plans. Rollovers from 403(b) plans, 401(a)/401(k) plans,
and IRAs to governmental 457(b) plans must be recordkept in separate rollover sources to limit the distributions that may be subject
to a 10% early distribution penalty.
4. YOUR FIDELITY ACCOUNT INFORMATION
If you do not have a retirement account with Fidelity for the employer listed here, you must complete the enroll-
ment process. For help with enrollment, please contact Fidelity at 1-800-343-0860 or for the hearing impaired
dial 711.
Employer Sponsoring Your Fidelity Retirement Account: The employer name appears on your Fidelity account statement or
in your enrollment paperwork.
Plan Type with this employer: This information is required to ensure that Fidelity credits your assets to the proper account.
Please contact Fidelity at 1-800-343-0860 or for the hearing impaired dial 711 if you do not know your plan type.
Plan Number: Please provide the plan number if you have multiple retirement plan accounts with Fidelity. Please contact Fidelity at
1-800-343-0860 or for the hearing impaired dial 711 to obtain the plan number.
022380001
5. INVESTMENT INSTRUCTIONS
Would you like the assets invested in your current investment selection? If “Yes” is selected, your assets will
be allocated to your current investment selection on file with Fidelity. If you do not select “Yes,” please list the fund
names, fund codes (if known), and percentages. Please ensure that the percentages equal 100%. Please list any
additional funds on a separate page and attach it to this form.
Fund Name: List the fund name(s) you want your assets credited to.
Fund Code: Provide the four-digit fund code(s) (if known).
Percentage: Please ensure that the percentages listed equal 100%.
Note: If no investment options are selected, your investment instructions are incomplete or invalid, or the percentages listed are
less than or exceed 100%, your entire contribution will be defaulted to the investment elections on file with Fidelity. If you have no
investment elections on file, your entire contribution will be defaulted to the investment option specified in the agreement currently
in place with Fidelity for the Plan.
6. EMPLOYER PLAN ACCEPTANCE
Employer Authorized Signature: An authorized signature from the employer that sponsors your Fidelity retirement account may
be required. To verify if this section needs to be signed, contact your Human Resources office or Fidelity at 1-800-343-0860 or for
the hearing impaired dial 711.
7. SIGNATURE AND DATE
Please read the legal information provided in this section and then sign and date the form. We
are unable to process your request without your signature and the date.
Transfer/Rollover/Exchange Form Checklist:
Here is a checklist to ensure that your request is in good order.
Please remember to:
Include your most recent account statement from your previous investment provider.
Indicate the amount or percentage of money you are moving to Fidelity.
Obtain the Employer Authorized Signature. Contact your Human Resources office or Fidelity to verify if this
is required.
Sign and date in Section 7 of the form.
OR
If you are sending this using an overnight delivery
Return to: service, please send to:
Fidelity Investments Fidelity Investments
100 Crosby Parkway, Mailzone KC1E
Cincinnati, OH 45277-0090 Covington, KY 41015
Please contact your previous investment provider to see if additional paperwork is required.
Use this checklist to ensure your request is complete:
Remember to return all pages of this form.
Include your most recent account statement from your previous investment provider.
Indicate the amount or percentage of money you are moving to Fidelity.
Sign and date Section 7 of this form.
Please contact your previous provider to see if additional paperwork is required.
Return completed form in a legible condition.
Ways to Return This Form to Fidelity:
Digitally using the
NetBenefits
®
Mobile App
Download the NetBenefits
®
app
Tap: Actions > Send a Document
Regular Mail
Fidelity Investments
PO Box 770002
Cincinnati, OH 45277-0090
Questions?
Call 800-343-0860 or for the hearing impaired dial 711, business days (except NYSE holidays) from 8:00AM – Midnight ET
or go to www.Netbenefits.com/atwork.
Overnight Mail
Fidelity Investments
100 Crosby Parkway, Mailzone KC1E
Covington, KY 41015
t
through the App Store
®
or Google Play
TM
store.
Transfer/Rollover/Exchange Form
Instructions: Use this form to move assets to your Fidelity employer-sponsored retirement account from a previous investment
provider. You may also use this form to consolidate multiple employer-sponsored retirement accounts currently at Fidelity. If you do not
have a retirement account with Fidelity, you must also complete an Account Application/Enrollment Form or, when available,
enroll online at netbenefits.com/atwork. If your current employer does not offer a retirement plan recordkept by Fidelity, your
employer needs to establish a retirement plan prior to your vendor or contract exchange, or rollover to a Fidelity account. An
incomplete form may delay the processing of your request. Use a separate form for each investment provider.
Unless otherwise instructed by your employer, please return this transfer/rollover/exchange form in the postage-paid envelope
provided OR
Return to: If you are sending this using an overnight delivery
Fidelity Investments service, please send to:
Fidelity Investments
100 Crosby Parkway, Mailzone KC1E
Covington, KY 41015
Questions? Call Fidelity Investments at 1-800-343-0860 or for the hearing impaired dial 711, Monday through Friday, 8 a.m.
to midnight Eastern time (excluding New York Stock Exchange holidays, except Good Friday), for assistance with completing this form.
1. YOUR INFORMATION
Please use a black pen and print clearly in CAPITAL LETTERS.
Social Security # or Tax ID #:
Date of Birth:
First Name: Middle Initial:
Last Name:
Mailing Address:
City: State:
ZIP Code:
Daytime Phone: Evening Phone:
Email:
2. INVESTMENT PROVIDER YOU ARE MOVING MONEY FROM
Name of investment provider you are moving money from
Please include a copy of your most recent account statement from your investment provider.
Provider Street Address:
City:
State:
ZIP Code:
Provider Phone: Ext:
Please contact your previous investment provider to see if additional paperwork is required. Use a separate form for each
investment provider.
Page 1
(e.g., VALIC, TIAA-CREF, Vanguard, Voya, Lincoln):
022380003
Unless otherwise instructed by your employer, please return this completed form, along with a copy of a recent statement:
Digitally with:
NetBenefits
®
Mobile App
Download the NetBenefits
®
app
Tap:
Actions > Send
a Docum
ent
Or use one of these alternate methods:
AIG Retirement, TIAA-CREF, Vanguard, Voya, Lincoln):
:
Regular Mail
Fidelity Investments
PO Box 770002
Cincinnati, OH 45277-0090
Overnight Mail
Fidelity Investments
100 Crosby Parkway, KC1E
Covington, KY 41015
through the App Store
®
or Google Play
TM
store.
3. ACCOUNT(S) OR CONTRACT(S) TO MOVE
Please provide information about the account(s)/contract(s) you wish to move to Fidelity. If no account or contract
numbers are provided, we will use your Social Security number or U.S. Tax ID number to request the assets to be moved.
Please make additional copies of this page and the next page if you have more than two accounts/contracts to move.
3A. FIRST ACCOUNT/CONTRACT (if more than one account/contract, please complete section 3B in addition to section 3A)
1. Account/Contract #:
Type: 403(b) Include Roth 403(b) balance 401(a)/(k) Include Roth 401(k) balance
457(b) governmental Include Roth 457(b) governmental balance IRA
2. Please check the box that most accurately reflects the transaction that you are requesting. Note that your selection will
dictate how we process this transaction. Please read Section 3 of the instructions for more details.
The Same Employer as My Employer Plan with Fidelity
A Previous Employer
Previous Employer Name:
A Rollover IRA
A Traditional IRA or SEP IRA
3. Liquidation Amount
Full Liquidation/100% Partial Liquidation % OR $
Unless otherwise specified, I request the
previous investment provider to liquidate
100% of my account.
3B. SECOND ACCOUNT/CONTRACT (if applicable).
1. Account/Contract #:
Type: 403(b) Include Roth 403(b) balance 401(a)/(k) Include Roth 401(k) balance
457(b) governmental Include Roth 457(b) governmental balance IRA
2. Please check the box that most accurately reflects the transaction that you are requesting. Note that your selection will
dictate how we process this transaction. Please read Section 3 of the instructions for more details.
The Same Employer as My Employer Plan with Fidelity
A Previous Employer
Previous Employer Name:
A Rollover IRA
A Traditional IRA or SEP IRA
3. Liquidation Amount
Full Liquidation/100% Partial Liquidation % OR $
Unless otherwise specified, I request the
previous investment provider to liquidate
100% of my account.
(select one)
Page 2
(select one)
(select at
least one)
(select at
least one)
4. YOUR FIDELITY ACCOUNT INFORMATION
If you do not have a retirement account with Fidelity for the employer listed below, or you do not know the plan
number or type, please contact Fidelity at 1-800-343-0860 or for the hearing impaired dial 711.
5. INVESTMENT INSTRUCTIONS
Would you like the assets invested in your current investment selection? Yes No (specify below)
Fund Name(s): Fund Code: Percentage:
%
%
%
%
If no investment options are selected, your investment instructions are incomplete or invalid, or the percentages listed are less than
or exceed 100%, your entire contribution will be defaulted to the investment elections on file with Fidelity. If you have no investment
elections on file, your entire contribution will be defaulted to the investment option specified in the agreement currently in place with
Fidelity for the Plan.
6. EMPLOYER PLAN ACCEPTANCE
An authorized signature from the employer that sponsors your Fidelity retirement account may be required. To verify if
this section needs to be signed, contact your Human Resources office or Fidelity at 1-800-343-0860 or for the hearing impaired
1-800-259-9743 (TTY).
Employer Authorized Signature:
X
Date:
Employer Authorized Printed Name:
X
Page 3
OR
OR
OR
OR
Total = 100%
Employer Sponsoring Your Fidelity Retirement Account:
(This name appears on your Fidelity statement, or in your enrollment paperwork.)
City & State of Employer:
Are you still employed with this Employer?
Yes
No
4A. Fidelity Account Information for 3A
Plan Type:
403(b)
401(a)/(k)
457(b) governmental
Plan Number (if known):
4B. Fidelity Account Information for 3B
Plan Type:
403(b)
401(a)/(k)
457(b) governmental
Plan Number (if known):
If there is a discrepancy between plan type and plan number, the plan type selected will be used.
4. YOUR FIDELITY ACCOUNT INFORMATION
If you do not have a retirement account with Fidelity for the employer listed below, or you do not know the plan
5. INVESTMENT INSTRUCTIONS
Would you like the assets invested in your current investment selection? Yes No (specify below)
Fund Name(s): Fund Code: Percentage:
%
%
%
%
If no investment options ar
e selected, your investment instructions ar
e incomplete or invalid, or the percentages listed are less than
or exceed 100%, your entire contribution will be defaulted to the investment elections on file with Fidelity. If you have no investment
elections on file, your entire contribution will be defaulted to the investment option specified in the agreement currently in place with
Fidelity for the Plan.
6. EMPLOYER PLAN ACCEPTANCE
An authorized signature from the employer that sponsors your Fidelity retirement account may be required. To verify if
this section needs to be signed, contact your Human Resources office or Fidelity at 1-800-343-0860 or for the hearing impaired
1-800-259-9743 (TTY).
Employer Authorized Signature:
X
Date:
Employer Authorized Printed Name:
X
Page 3
OR
OR
OR
OR
Total = 100%
Employer Sponsoring Your Fidelity Retirement Account:
(This name appears on your Fidelity statement, or in your enrollment paperwork.)
City & State of Employer: Are you still employed with this Employer? Yes No
4A. Fidelity Account Information for 3A
Plan Type: 403(b) 401(a)/(k) 457(b) governmental
Plan Number (if known):
4B. Fidelity Account Infor
mation for 3B
Plan Type: 403(b)
401(a)/(k) 457(b) governmental
Plan Number (if known):
If ther
e is a discrepancy between plan type and plan number, the plan type selected will be used.
4. YOUR FIDELITY ACCOUNT INFORMATION
5. INVESTMENT INSTRUCTIONS
Would you like the assets invested in your current investment selection? Yes No (specify below)
Fund Name(s): Fund Code: Percentage:
%
%
%
%
If no investment options are selected, your investment instructions are incomplete or invalid, or the percentages listed are less than
or exceed 100%, your entire contribution will be defaulted to the investment elections on file with Fidelity. If you have no investment
elections on file, your entire contribution will be defaulted to the investment option specified in the agreement currently in place with
Fidelity for the Plan.
6. EMPLOYER PLAN ACCEPTANCE
An authorized signature from the employer that sponsors your Fidelity retirement account may be required. To verify if
this section needs to be signed, contact your Human Resources office or Fidelity at 1-800-343-0860 or for the hearing impaired
dial 711.
Employer Authorized Signature:
X
Date:
Employer Authorized Printed Name:
X
Page 3
OR
OR
OR
OR
Total = 100%
Employer Sponsoring Your Fidelity Retirement Account:
(This name appears on your Fidelity statement, or in your enrollment paperwork.)
City & State of Employer: Are you still employed with this Employer? Yes No
4A. Fidelity Account Information for 3A
Plan Type: 403(b) 401(a)/(k) 457(b) governmental
Plan Number (if known):
4B. Fidelity Account Infor
mation for 3B
Plan Type: 403(b)
401(a)/(k) 457(b) governmental
Plan Number (if known):
If ther
e is a discrepancy between plan type and plan number, the plan type selected will be used.
Page 4
7. SIGNATURE AND DATE
By signing this form:
• I hereby direct the investment provider identified on this form in Section 2 to liquidate the designated amount of the account(s)
listed on this form, and to release the proceeds to my account under my employer’s plan, except to the extent my current employer
or any of my former employers prohibit such release. In the event of such prohibition, I hereby direct said investment provider to
retain the portion of my account(s) that cannot be released in a separate account or contract and to release the remainder.
• I hereby agree to the terms and conditions stated in this form, including the instructions, and certify that I am requesting a vendor
or contract exchange, in-plan transfer, or rollover, of my retirement plan assets in accordance with applicable IRS and plan rules.
• I certify under the penalties of perjury that my Social Security number or U.S. Tax Identification number on this form is correct.
• I certify that the information provided on this form is true, accurate, and complete to the best of my knowledge.
• I acknowledge that I have read the prospectus(es) for any mutual fund in which I invest and agree to the terms.
• I hereby agree that if my assets will be sent to Fidelity in installments, the first installment may be invested according to my
instructions on this form. All subsequent installment payments as well as any residual balances not received within 30 days will
be invested according to the investment elections currently in place with Fidelity for the Plan at the time my assets are received
by Fidelity.
For 403(b)-to-403(b) vendor or contract exchanges
• I understand that any balances I am exchanging from a 403(b)(1) annuity into a 403(b)(7) custodial account may be subject to
more restrictive withdrawal provisions.
• I understand that if I exchange a contribution source that is not allowed by the Plan, the value associated with the unacceptable
source will be returned to the investment provider named in Section 2.
• I direct Fidelity to treat all monies as pretax contributions made subsequent to 12/31/88 unless my prior investment provider
provides Fidelity with account balances as of 12/31/88 and post-1988 salary reduction contributions.
• I direct Fidelity to treat the entire balances as subject to minimum distribution requirements unless my prior investment provider
provides Fidelity with account balances as of 12/31/86.
• I direct Fidelity to allocate the entire balance to the most restrictive source in the current employer’s plan unless my prior invest-
ment provider provides Fidelity with the sources of the exchanged amount under the previous plan.
Your Signature:
X
Date:
26030_02/0116
434261.14.0
Fidelity Investments Institutional Operations Company, Inc.
1.931026.105
Fidelity Investments Institutional Operations Company LLC.
:
The trademarks and service marks appearing herein are the property of their respective owners.
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TransferRolloverExchange Form Instructions (Fidelity Investments)

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Completed 17 February 2021

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