OMNI OnlineSM Secure Portal    Trouble Logging In? | Enroll Now
  User:   Password:      


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: 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®.

Employee Information

*Last Name:    *First Name:    MI: 
Maiden/Former Name:   
* Address:
* City: * State:   * Zip:
* Phone: Alternate Phone:
* Email: * Re-enter Email:
* SS#: (9 digits, no dashes or spaces) * Date of Birth: (MM/DD/YYYY)

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: Current Employer Name (if different than account sponsor):

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:

Payee Information:

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

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    

Please note: Javascript must be enabled for this form to be properly submitted. If you are having difficulty submitting the form, please ensure that your browser settings enable Javascript usage.

OMNI P3 and OMNIOnline are service marks of Omni Financial Group, Inc. d/b/a U.S. OMNI  | ©2018 Omni Financial Group, Inc.   ALL RIGHTS RESERVED
Facebook Twitter Facebook Participants Employers Advisors Experience Protection Service Education Experience Protection Service Education