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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:
After verifying your eligibility to receive a Hardship Withdrawal, 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.
Current Employer: PLEASE NOTE: Hardship disbursements may be possible ONLY against your CURRENT employer's plan. For disbursement options from plans sponsored by previous employers, please contact OMNI®.

*Employer State: *Employer Name:

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)
Date of Separation: (MM/DD/YYYY)

Service Provider Agent Information:

Tax Sheltered Annuity Account Information:

I am requesting to take a Hardship distribution from my current employer's 403(b) account:
*Service Provider Company:
If other, please supply company name here:
Account #:
*Amount Requested:

Hardship Circumstances:
Please see our OMNI® 403(b) Hardship Information Sheet for a list of acceptable documentation.

*Please identify which of the following circumstances have prompted this request for disbursement:

Medical care expenses previously incurred by the employee, the employee's spouse, any dependents of the employee, or the employee's primary beneficiary under the 403(b) plan, necessary for these persons to obtain medical care (you must provide supporting documentation, e.g. doctor's certification, hospital bills, explanation of benefits by insurance company).
Costs directly related to the purchase of a principal residence for the employee (excluding mortgage payments) (you must provide supporting documentation);
Payment of tuition, related educational fees, and room and board expenses, for the next 12 months of post-secondary education of the employee, or the employee's spouse, children, dependents, or primary beneficiary under the 403(b) plan (you must provide supporting documentation);
Payment necessary to prevent eviction of the employee from the employee's principal residence or foreclosure on the mortgage on that residence (you must provide supporting documentation, e.g. bank's foreclosure notice);
Payment of funeral expenses for the employee's spouse, dependent, or primary beneficiary under the 403(b) plan (you must provide supporting documentation, e.g. death certificate, funeral home bill);
Certain expenses relating to the repair of damage to the employee's principal residence (you must provide supporting documentation, e.g. proof of loss, contractor's estimates, insurance adjuster's estimates).

*Date Hardship First Occurred:   

If total amount being requested is not fully represented by supporting documentation, how did you arrive at the amount?:

Alternative Measures:

Please answer the following questions:

* 1. Will suspending your current elective deferrals to your 403(b) or 457 accounts alleviate your Hardship?
* 2. Are there distributions available to you under the plan or any other plans maintained by your employer that will alleviate the Hardship?
* 3. Can you receive reimbursement from insurance or other sources to pay these expenses?
* 4. Can you secure a commercial loan to pay these expenses?
* 5. Can you liquidate assets to pay these expenses?
* 6. Are you eligible to take a loan from any 403(b) account or any other retirement plans offered by your employer?

If yes to Item #6, you must take any eligible loans before requesting this distribution unless doing so would result in an additional financial hardship. If this is the case, please explain below how taking out a loan would present an additional financial hardship.



If approved for this distribution, I understand that:
  • The OMNI® Group is required to stop any salary reductions that might currently be in effect.
  • This hold must remain in effect for 6 months.
  • After the 6 month restriction period has ended, my contribution(s) will be automatically restarted in accordance with my most recent Salary Reduction Agreement(s).
  • I am not required to resume salary reductions, and may submit a Salary Reduction Agreement at any time to stop further deferrals.
By clicking the "Continue" button below, I hereby confirm that the information on this form is correct and complete to the best of my knowledge. I understand that requests without adequate supporting documentation, including my Service Provider's form(s), cannot be processed.

*Re-enter Social Security # to verify:

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