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

TRANSACTION TYPE: Rollover

Movement of funds to a 403(b) account from any other type of account such as an IRA, 401(k), 401(a), etc. 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:



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Receiving Account Information:




Confirmation:


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