403(b) PLAN DISBURSEMENT REQUEST FORM for Renton School Dist. NO 403 [Renton, WA]

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.

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.