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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:
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)

Service Provider Agent Information:

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 #:
*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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