U.S. OMNI - Transaction Forms

403(b) PLAN DISBURSEMENT REQUEST FORM for City of St. Charles School Dist. [St. Charles, MO]

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.

The tracking number for your request is .
We will review your request and advise.

Employee Information

Last Name *

First Name *

Middle Initial

Maiden Name

Address *

City *

State *

Zip *

Phone *

Alternate Phone

Email *

Re-enter Email *

Social Security Number *

Date of Birth *

Date of Separation

Investment Provider Agent Information:

There is a financial advisor/representative associated with this transaction.

Agent Name *

Agent Phone *

Agent Email *

Agent Fax

I wish the above named agent to be copied on all e-mail communications sent to the plan participant, including certificate(s) of approval, which may be associated with this transaction.

Tax Sheltered Annuity Account Information:

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

Investment Provider Company

If other, please supply company name here

Account #

Amount Requested (Max $5000.00) *

Child Name *

Confirmation:

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

Re-enter Social Security Number: *:

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