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OMNI® 403(b) PLAN DISBURSEMENT REQUEST FORM

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 this form before submitting.
  • Fields having an asterisk notation are required.

Transaction Type:
*Type: Disbursement of funds from a deceased participant's 403(b) account. Original death certificate must be provided with Service Provider paperwork mailed/faxed to OMNI®. For more details, please visit our Transaction Information page or contact OMNI®.


Decedent Information

*Last Name:    *First Name:    MI: 
Maiden/Former Name:   
  
* SS#: (9 digits, no dashes or spaces)


Service Provider Agent Information:



Distributing Account Information:

Please provide the information for the employer from whose Plan you wish to withdraw funds:
*Employer State: *Employer Name:

Please provide the following information for the Service Provider who will be distributing (paying out) the funds for this transaction:

*Service Provider Company:
If other, please supply company name here:
Account #:
*Amount Requested:


Beneficiary Information:

*Last Name:    *First Name:    MI: 
*Address:
*City: *State:    * Zip:
*Phone: Alternate Phone:
*Email: *Re-enter Email:


Confirmation:
By clicking the button below labled "Continue", I hereby confirm that the information on this form is correct and complete to the best of my knowledge.

*Re-enter Social Security # to verify:

Additional instructions will appear on the next screen    


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