403(b) PLAN DISBURSEMENT REQUEST FORM for Regional School District #17 [Higganum, CT]

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:
After verifying your eligibility to receive a Hardship Withdrawal, OMNI will sign off on your transaction and, unless otherwise notified, forward it directly to your Service Provider so that your funds may be issued.

Further information regarding IRS regulations relating to this subject can be found at the IRS website or in the 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 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.