403(b) PLAN DISBURSEMENT REQUEST FORM for Conejo Valley Unified School District [Thousand Oaks, CA]

TRANSACTION TYPE: Hardship

Please Note: This form version MUST be completed online. For a downloadable verison to submit via mail or fax, please click here.

IMPORTANT NOTICE: Before You Sign, Read All Information on this form:
Further information regarding IRS regulations relating to this subject can be found at the IRS website or in the 2009 IRS Publication 571.
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 Hardship distribution from my current employer's 403(b) account:


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Hardship Circumstances

Please see our OMNI 403(b) Hardship Information Sheet for a list of acceptable documentation.

*Please identify which of the following circumstances have prompted this request for disbursement:
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Alternative Measures

Please answer the following questions:
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Yes   No  
*2.
Yes   No  
*3.
Yes   No  
* I have read the OMNI/TSACG 403(b) Hardship Information Sheet and am aware of the criteria necessary to qualify for a distribution.

Confirmation:


I certify that the hardship distribution requested is for an immediate and heavy financial need, does not exceed the amount of the need, and have no alternative means reasonably available to satisfy the need.