Step 1 of 3: Supply Information | Step 2 of 3: Confirm Entries | Step 3 of 3: Submission Confirmation
Please Note: This form version MUST be completed online.
For a downloadable version to submit via mail or fax, please click here
IMPORTANT NOTICE: Before You Sign, Read All Information on this form:
- Please supply the information requested below.
- Read all agreements on this form before submitting.
- Fields having an asterisk notation are required.
Many 403(b) Service Providers allow for participants to take a loan against the assets held in their plan. If your Service Provider allows for loans, you will start the process by contacting them directly to request this transaction. It is important to note that Loans will need to be repaid (with interest). Your Service Provider will work with you to decide on the technicalities of your loan, including the manner in which it will be repaid. After completing your Service Provider's Loan Paperwork, fax it along with this form to OMNI's Service Provider Team at 585-756-5557 (or mail, if original paperwork is required).
After verifying your eligibility to receive a loan, OMNI® will sign off on your transaction and, unless otherwise notified, forward it directly to your Service Provider so that your funds may be issued.
Further information regarding IRS regulations relating to this subject can be found at the IRS website
or in the 2009 IRS Publication 571
403(b) Plan Sponsor:
Please provide the information for the employer from whose plan you wish to withdraw funds.