U.S. OMNI - Transaction Forms

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.

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 *

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

Agent Name *

Agent Phone *

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.

I am requesting to take a Hardship distribution from my current employer's 403(b) account:

Investment Provider Company

If other, please supply company name here

Account #

Amount Requested *

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:

Medical care expenses previously incurred by the employee, the employee's spouse, any dependents of the employee, or the employee's primary beneficiary under the 403(b), necessary for these persons to obtain medical care (you must provide supporting documentation, e.g. doctor's certification, hospital bills).

Costs directly related to the purchase of a principal residence for the employee (excluding mortgage payments) (you must provide supporting documentation);

Payment of tuition, related educational fees, and room and board expenses, for the next 12 months of post-secondary education of the employee, or the employee's spouse, children, dependents, or primary beneficiary under the 403(b) plan (you must provide supporting documentation);

Payment necessary to prevent eviction of the employee from the employee's principal residence or foreclosure on the mortgage on that residence (you must provide supporting documentation, e.g. bank's foreclosure notice);

Payment of funeral expenses for the employee's spouse, dependent, or primary beneficiary under the 403(b) plan (you must provide supporting documentation, e.g. death certificate, funeral home bill);

Certain expenses relating to the repair of damage to the employee's principal residence (you must provide supporting documentation, e.g. proof of loss, contractor's estimates, insurance adjuster's estimates).

Expenses and losses (including loss of income) incurred by the Employee on account of a FEMA declared disaster, provided that the Employee's principal residence or principal place of employment at the time of the disaster was located in an area designated by FEMA for individual assistance with respect to the disaster.

Date Hardship First Occurred *

If total amount being requested is not fully represented by supporting documentation, how did you arrive at the amount?:

Please answer the following questions:

*1. Is the amount requested more than the amount required to satisfy your financial need (including any amounts necessary to pay any federal, state or local income taxes or penalties reasonably anticipated to result from the distribution)?
Yes No

*2. Do you have available distributions, other than a hardship distribution or loan, under any other plan?
Yes No

*3. Do you have sufficient cash or other liquid assets to satisfy your financial need?
Yes No

* I have read the OMNI 403(b) Hardship Information Sheet and am aware of the criteria necessary to qualify for a distribution.

Confirmation:

I hereby confirm that the information on this form is correct and complete to the best of my knowledge. I understand that requests without adequate supporting documentation, including my Service Provider's form(s), cannot be processed.

Re-enter Social Security Number to confirm *: