Fidelity Transfer / Rollover Form Page 2
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43. YOUR PREVIOUS INVESTMENT PROVIDER (CONTINUED)
Please indicate below the contract(s) or account(s) you are authorizing for liquidation, using a separate section for each contract
or account number.
A. Account or contract number:
Percentage
%
OR
Dollar Amount $
,
Type of Account to be transferred or rolled over:
403(b) OR
401(a)/401(k) OR
457(b) governmental OR
457(b) non-governmental OR
IRA
If you know the type of assets you are moving, check here:
Employee
After tax
Employer
These assets are coming from (Please check only one):
Same Employer Plan as listed in Section 2
Previous Employer Plan; Please list name:
Traditional/SEP IRA
Rollover IRA (which contains rollover assets only; no after-tax contributions)
An eligible rollover distribution from a retirement plan that was paid directly to me. (See instructions)
B. Account or contract number:
Percentage
%
OR
Dollar Amount $
,
Type of Account to be transferred or rolled over:
403(b) OR
401(a)/401(k) OR
457(b) governmental OR
457(b) non-governmental OR
IRA
If you know the type of assets you are moving, check here:
Employee
After tax
Employer
These assets are coming from (Please check only one):
Same Employer Plan as listed in Section 2
Previous Employer Plan; Please list name:
Traditional/SEP IRA
Rollover IRA (which contains rollover assets only; no after-tax contributions)
An eligible rollover distribution from a retirement plan that was paid directly to me. (See instructions)
C. Account or contract number:
Percentage
%
OR
Dollar Amount $
,
Type of Account to be transferred or rolled over:
403(b) OR
401(a)/401(k) OR
457(b) governmental OR
457(b) non-governmental OR
IRA
If you know the type of assets you are moving, check here:
Employee
After tax
Employer
These assets are coming from (Please check only one):
Same Employer Plan as listed in Section 2
Previous Employer Plan; Please list name:
Traditional/SEP IRA
Rollover IRA (which contains rollover assets only; no after-tax contributions)
An eligible rollover distribution from a retirement plan that was paid directly to me. (See instructions)
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