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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.
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Your employer’s 403(b) plan permits eligible participants to utilize the Service Based Catch-Up provision. This catch-up permits employees with 15 or more years of service to contribute up to an additional $3000 beyond their base limit, allowing individuals over age 50 to contribute $28000 in 2019 ($22000 for employees under age 50.) In addition, a 403(b) participant must have contributed less than an average of $5,000/year over the course of their employment. By submitting the electronic form below, you request that OMNI determine your eligibility to utilize the Service Based Catch-Up.

403(b) Plan Sponsor:
Please provide the information for the employer with whom you'd like to utilize Service Based Catch-Up.

*Employer State: *Employer Name: *Date of Hire: (MM/DD/YYYY)

Participant Information:

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

By clicking the button below labeled "Continue", I hereby request that OMNI calculate my eligibility for the Service Based Catch-Up, and update my Maximum Allowable Contribution (MAC) based upon the outcome of such calculation(s). I understand that OMNI will monitor my MAC on an ongoing basis, and that I will retain the opportunity to utilize the Service Based Catch-Up until such a time as my eligibility has been exhausted.

*Re-enter Social Security # to verify:

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