403(b) PLAN Coronavirus Related DISTRIBUTION REPAYMENT 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.
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Transaction Type:

Coronavirus Related Distribution REPAYMENT

The Coronavirus Aid, Relief and Economic Security (CARES) Act permits a Coronavirus related distribution for up to $100,000. As part of this legislation, participants are permitted to repay all or a portion of the distribution into their 403(b) for up to three years from the day after the date of the distribution. These repayments are not subject to the maximum allowable contribution limits of the Plan, and will be treated as a rollover contribution.

This form is used to instruct your employer to withhold pre-tax payroll deductions solely for the purpose of repaying of a previously taken a Coronavirus Related Distribution. Deductions may be designated as recurring for a specified number of pay periods or as a one-time, lump-sum repayment.

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:




Current Employer Information:


Please provide the full Organization Name, City and State for the employer from whose pre-tax payroll these deductions will be made:
*Employer Name: Current Employer Name (if different than account sponsor):
Andover Public Schools

Coronavirus Distribution Deduction Information:


*Please provide the following information about the distribution(s) taken and the repayment deduction amount(s) desired:
If distribution(s) being repayed was/were distributed from a DIFFERENT or FORMER employer's plan, please provide the full Organization Name, City and State for that employer:
Service ProviderROTHAccount #Total Distribution
Amount Received
Total Amount
to be Repaid
Deduction Amount
Per Pay Period
Number of
Pay Periods
Date on which to
Begin Deductions


Confirmation:

The above named Employee where applicable, agrees as follows:
  1. That the repayment is for the Coronavirus related distribution.
  2. That the repayment is no more than the amount of the Coronavirus related distribution.
  3. This Coronavirus Related Distribution Payroll Deduction Repayment form is legally binding and irrevocable with respect to amounts paid.
  4. This Coronavirus Related Distribution Payroll Deduction Repayment form may be changed with respect to amounts not yet paid.
  5. This Coronavirus Related Distribution Payroll Deduction Repayment form may be terminated at any time for amounts not yet paid or available, and that a termination request is permanent and remains in effect until a new Coronavirus Related Distribution Payroll Deduction Repayment form is submitted.
  6. To be responsible for setting up and signing the legal documents necessary to establish an account for which the repayment is made.
By submitting this agreement to TDS, I hereby confirm that the information on this form is correct and complete to the best of my knowledge. I understand my responsibilities as an Employee under this Coronavirus Related Distribution Payroll Deduction Repayment form, and I request that Employer take the action specified in this agreement.

*Re-enter Social Security # to verify:

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