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
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
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.