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

TRANSACTION TYPE: Qualified Domestic Relations Order

Eligible distribution from a 403(b) account for the participant to an alternate payee under the terms of a court order. For more details, please visit our Transaction Information page or contact OMNI.
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:

*
*
*

Distributing Account Information:


*

Payee Information:

*
*
*
*
*
*
*
*
*

Confirmation:


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