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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.
  • Please supply the information requested below.
  • Read all agreements on this form before submitting.
  • Fields having an asterisk notation are required.
IMPORTANT NOTICE: Before You Sign, Read All Information on this form:
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.

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

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)
OMNI Tracking ID (if known):

Tax Sheltered Annuity Account Information:

I am requesting to take a loan from the following 403(b) account:
*Service Provider Company:
If other, please supply company name here:
Account #:
Name of Agent or Broker:
Agent/Broker Phone:
*Amount Requested:

If amount requested is not available, OMNI will process for maximum amount available at the time this form is received in good order.

Account and Loan History:

I have previously taken out a loan.

Account # Approximate Value Outstanding Loan Balance Status

Other Accounts:

Please complete the following statements:

1. I have other accounts under this Plan.

If yes, please provide the following:
Service Provider Name Account Number Approximate Value Outstanding Loan Balance Status

2. I have accounts in other plans of this employer.

If yes, please provide the following:
Account Type Service Provider Name Account Number Approximate Value Outstanding Loan Balance Status

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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