How to Fill Out the Nationwide Rollover Form: Sections and Signature

The Nationwide rollover form, officially the Nationwide Retirement Solutions Incoming Assets Form (NRI-0136AO), is the document you complete to move retirement savings from an outside qualified plan or IRA into your Nationwide account. You can download it from the forms section at nrsforu.com or get a copy from your employer’s benefits coordinator. Once Nationwide receives both the completed form and the transferred funds, it deposits the money into your account within five business days, though the prior institution’s release of funds can take considerably longer. The form covers rollovers and transfers from 401(k), 403(b), 457(b), 401(a), and traditional or Roth IRAs.¹

What to Gather Before You Start

Call the financial institution that currently holds your retirement money before you open the form. That company will have its own paperwork and release procedures, and you need specific details from them to complete the Nationwide side. The form itself notes that the surrendering institution “will likely have their own requirements to complete the rollover/transfer,” so confirming this up front avoids discovering mid-process that they need a separate authorization.¹

Have these in front of you:

The current custodian’s full name and address, your account number there, and a contact name and phone number for their retirement plan department.
The exact account type: 401(k), 403(b), 457(b), 401(a), traditional IRA, Roth IRA, or other qualified plan. Getting this wrong can stall the transfer.
If any portion of the rollover includes Roth contributions or after-tax money: the Roth basis amount, the year of your first Roth contribution, and any after-tax basis. The form has separate fields for these.
Your Nationwide plan details, meaning your employer’s name and employer number and the plan name and plan type. Your benefits coordinator or your Nationwide online dashboard will have these.

Filling Out the Form

Personal Information

The top section asks for your full name, Social Security number, date of birth, date of hire, street address, city, state, ZIP code, phone numbers, department, and email. Every field matters for verification. If Nationwide cannot match your identity to the incoming funds, the deposit stalls. The section also asks for your employer name and employer number, which tie the rollover to the correct plan.¹

Rollover/Transfer Funds From

This section identifies where the money is coming from. Check the box for the account type (401(a), 403(b), 457(b), 401(k), IRA, or other), then fill in the carrier or custodian name, account number, contact name, contact phone number, and the institution’s address. Check the account number against a recent statement. Transposed digits are one of the most common reasons transfers get kicked back.¹

Rollover/Transfer Funds To

Enter the dollar amount of the rollover or transfer, the Nationwide plan name and plan type, and whether any of the assets are Roth or after-tax money. If Roth assets are included, enter the Roth basis and the year of your first Roth contribution. For after-tax assets, enter the after-tax basis. Skipping these fields when they apply creates tax-reporting problems later, because Nationwide has to track the taxable and non-taxable portions of your account separately.¹

The 457(b)-to-457(b) Section

If you are moving money from one 457(b) plan to another 457(b) plan, complete the dedicated section on the second page. This is not optional. The form states it will not be processed if you skip this section when a 457(b) plan is involved. Enter the date you separated from the employer sponsoring the old 457(b) and choose whether the transaction is a transfer or a rollover. A transfer moves money directly between two 457(b) plans without a taxable event; a rollover carries different reporting requirements.¹

Investment Allocation

You have two choices. Check the box to allocate the rollover according to the investment mix already on file for your existing Nationwide contributions, or specify a custom allocation by listing individual investment options with percentages that total 100%. If you leave this section blank, Nationwide defaults to your current allocation. If you select a fund that is closed, the money goes into the Nationwide Money Market Fund instead.¹

Direct Rollover Is the Default

The Nationwide form is built for a direct rollover, also called a trustee-to-trustee transfer. You submit the form, and Nationwide coordinates with the surrendering institution to move the funds. No taxes are withheld, and no 60-day deadline applies.

An indirect rollover is different. The old institution cuts a check to you personally, and federal law requires it to withhold 20% of the taxable portion for income taxes.² You then have 60 days to deposit the full original amount, including replacing that 20% out of your own pocket, into the new Nationwide account.³ If you deposit only the 80% you actually received, the missing 20% is treated as a taxable distribution, plus a 10% early withdrawal penalty if you are under age 59½.⁴ Use the direct route and none of this applies.

Medallion Signature Guarantee

The Nationwide form notes that a Medallion Signature Guarantee may be required and tells you to confirm with your surrendering institution.¹ Whether you need one depends on that institution’s policies. Many require it for transfers above a certain dollar threshold or when moving securities out of brokerage accounts. A Medallion Signature Guarantee is not the same as a notarized signature. You get one from a bank, credit union, or broker-dealer that participates in a recognized medallion program.⁵ Fees range from nothing for existing account holders up to around $100. Call ahead and bring a valid photo ID.

How to Submit the Form

Sign and date the authorization section, then send everything to Nationwide through one of three channels:

Fax: 1-877-677-4329. This is the fastest paper-based option and gives you a transmission confirmation.
Standard mail: Nationwide, FBO [Your Name, SSN or Account Number], PO Box 183150, Columbus, OH 43218.
Overnight courier: Nationwide Retirement Solutions, Nationwide Insurance, 1 Nationwide Plaza, 1-LC-F2, Columbus, OH 43215-2239.

Include any paperwork the surrendering institution requires alongside the Nationwide form. If the old institution needs its own outgoing transfer form, send that directly to them; the Nationwide form alone does not authorize the release of funds from every custodian. The Nationwide form does state, however, that if funds are not already in transit, Nationwide will forward all paperwork to the relinquishing institution on your behalf.¹

What Happens After You Submit

Once Nationwide receives your form, it contacts the surrendering institution to coordinate the asset release. Nationwide deposits the proceeds into your account within five business days of receiving the money. The bottleneck is usually on the old institution’s end. Some custodians process outgoing transfers in a few days, others take weeks, and the form warns that certain account types can take up to 90 days.¹

Monitor your Nationwide account online for the status to shift from pending to deposited. If nothing moves after two to three weeks, call both Nationwide and the old institution to find out which side is holding things up. Common sticking points include a missing Medallion Signature Guarantee, a mismatched Social Security number between the two institutions, or an incomplete 457(b) section on the form. Catching these early saves you from starting over.

What Cannot Be Rolled Over

Not every dollar leaving a retirement account is eligible. The IRS prohibits rolling over several categories of distributions, and putting ineligible money into a new account creates an excess contribution that triggers a 6% excise tax for every year it stays there. The most common ineligible distributions:

Required minimum distributions once you reach RMD age.
Hardship distributions from a 401(k).
Substantially equal periodic payments under IRC Section 72(t).
Loans treated as deemed distributions after default.
Corrective distributions of excess contributions and related earnings.

For IRA distributions the ineligible list is shorter, mainly RMDs and excess contribution corrections, but the consequences of rolling over ineligible funds are the same.³

One more limit to know if you are consolidating IRAs: the IRS allows only one indirect IRA-to-IRA rollover across all your IRAs in any 12-month period, and the limit aggregates every IRA you own. Trustee-to-trustee transfers do not count toward this limit, so if you ask each old custodian to send the money directly to Nationwide, the one-per-year rule never enters the picture.³

1
Nationwide. Nationwide Retirement Solutions Incoming Assets Form
2
Office of the Law Revision Counsel. 26 USC 3405 – Special Rules for Pensions, Annuities, and Certain Other Deferred Income
3
Internal Revenue Service. Rollovers of Retirement Plan and IRA Distributions
4
Internal Revenue Service. Retirement Topics – Exceptions to Tax on Early Distributions
5
eCFR. 17 CFR 240.17Ad-15 – Signature Guarantees