U.S. OMNI - Transaction Forms

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

TRANSACTION TYPE: Death Claim

Disbursement of funds from a deceased participant's 403 account. A copy of the death certificate can be uploaded or faxed to OMNI. For more details, please visit our Transaction Information page or contact OMNI.

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.

Decedent Information

Last Name *

First Name *

Middle Initial

Maiden Name

Social Security Number *

The marital status on the death certificate was DIVORCED.

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.