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

TRANSACTION TYPE: Required Minimum Distribution

Required minimum distribution from Plan where participant is within the calendar year of attaining the age of 72 or later. 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

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Investment Provider Agent Information:

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Distributing Account Information:



Confirmation:


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