403(b) PLAN DISBURSEMENT REQUEST FORM for Regional School District #17 [Higganum, CT]

TRANSACTION TYPE: New Child Distribution

Please Note: This form version MUST be completed online.

IMPORTANT NOTICE: Before you sign, read all information on this form:
After verifying your eligibility to receive a New Child Distribution, pursuant to the SECURE Act of 2019, OMNI will sign off on your transaction and, unless otherwise notified, forward it directly to your Investment Provider so that your funds may be issued.

New Child Distribution requests require supporting documentation, birth certificate or adoption certificate, and must be accompanied by OMNI’s New Child Distribution request Form.

Further information regarding IRS regulations relating to this subject can be found at the IRS website.
Step 1 of 3: Supply Information
Step 2 of 3: Confirm Entries
Step 3 of 3: Submission Confirmation
  • Please supply the information requested below.
  • Read all agreements on the form before submitting.
  • Fields having an asterisk notation are required.

Employee Information

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Investment Provider Agent Information:

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Tax Sheltered Annuity Account Information:

I am requesting to take a New Child Distribution from my current employer's 403(b) account:


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Confirmation:


I hereby confirm that the information on this form is correct and complete to the best of my knowledge.