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

TRANSACTION TYPE: Loan

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

*
*
*
*
*
*
*
*
*
*
*

Investment Provider Agent Information:

*
*
*

Tax Sheltered Annuity Account Information:

I am requesting to take a loan from the following 403(b) account:

*
*
If amount requested is not available, OMNI will process for maximum amount available at the time this form is received in good order.

Account and Loan History:

* Yes   No  

Other Accounts:

*1. Yes   No  
*2. Yes   No  

Confirmation:


I hereby confirm that the information on this form is correct and complete to the best of my knowledge.