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.
- Fields having an asterisk notation are required.
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.
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:
Coronavirus Distribution Deduction Information: