403(b) PLAN Coronavirus Related DISTRIBUTION Request Form


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.
  • Fields having an asterisk notation are required.

Transaction Type:

Coronavirus Related Distribution

A participant is permitted to take a Coronavirus related distribution pursuant to the Coronavirus Aid, Relief, and Economic Security (CARES) Act for up to $100,000 if the participant:
  • is diagnosed with COVID-19; or
  • has a spouse or dependent who has been diagnosed with COVID-19; or
  • is experiencing adverse financial consequences as a result of being quarantined, furloughed, laid off, having work hours reduced, being unable to work due to lack of child care due to COVID-19, closing or reducing hours of a business owned or operated by the individual due to COVID-19; or
  • is experiencing a reduction in pay (or self-employment income) due to COVID-19 or had a job offer rescinded or start date for a job delayed due to COVID-19; or
  • has a spouse or a member of the participant’s household (someone who shares the participant’s principal residence) that is quarantined, furloughed or laid off, had work hours reduced due to COVID-19, unable to work due to lack of childcare due to COVID-19, had a reduction in pay (or self-employment income) due to COVID-19, or had a job offer rescinded or start date for a job delayed due to COVID-19; or
  • has a spouse or a member of his/her household that owns or operates a business and was forced to reduce hours or close due to COVID 19.
Please take note, income taxes apply to these distributions. Participants should consult with a financial advisor/tax advisor prior to compling this transaction.

For more details, please visit our COVID-19 CARES Act Information page or contact Tax Deferred Solutions.

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:




Distributing Account Information:


Please provide the information for the employer from whose Plan you wish to withdraw funds:
*Employer Name: Current Employer Name (if different than account sponsor):
Andover Public Schools

Please provide the following information for the Service Provider who will be distributing (paying out) the funds for this transaction:

*Service Provider Company:
If other, please supply company name here:
Account #:
*Amount Requested:


Distribution Circumstances:


Participant has been diagnosed with COVID-19
The participant’s spouse or dependent has been diagnosed with COVID-19
The participant is experiencing adverse financial consequences as a result of being quarantined, furloughed, laid off, having work hours reduced, being unable to work due to lack of child care due to COVID-19, closing or reducing hours of a business owned or operated by the individual due to COVID-19.
The participant is is experiencing a reduction in pay (or self-employment income) due to COVID-19 or had a job offer rescinded or start date for a job delayed due to COVID-19.
The participant has a spouse or a member of the participant’s household (someone who shares the participant’s principal residence) that is quarantined, furloughed or laid off, had work hours reduced due to COVID-19, unable to work due to lack of childcare due to COVID-19, had a reduction in pay (or self-employment income) due to COVID-19, or had a job offer rescinded or start date for a job delayed due to COVID-19
The participant’s spouse or a member of his/her household that owns or operates a business and was forced to reduce hours or close due to COVID 19.


Confirmation:

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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