U.S. OMNI - Transaction Forms

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

TRANSACTION TYPE: Domestic Abuse

An eligible distribution to a domestic abuse victim shall not exceed the lesser of:

$10,000 or;
50% of the vested investment provider balance.

The term "domestic abuse" means physical, psychological, sexual, emotional, or economic abuse, including efforts to control, isolate, humiliate, or intimidate the victim, or to undermine the victim's ability to reason independently, including by means of abuse of the victim's child or another family member living in the household. A "domestic abuse" victim has one year from the date of the abuse to receive this distribution.

You have three years to repay this distribution.

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

Address *

City *

State *

Zip *

Phone *

Alternate Phone

Email *

Re-enter Email *

Social Security Number *

Date of Birth *

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 Domestic Abuse Distribution from my current employer's 403(b) account:

Investment Provider Company

If other, please supply company name here

Account #

Amount Requested *

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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