403(b) Coronavirus Related LOAN Request Form


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:
A coronavirus related loan permits a participant to take a loan in the amount $100,000 or 100% of the participant’s vested account balance if the participant:
  • is diagnosed with COVID-19;
  • 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.
  • is experiencing a reduction in pay (or self-employment income) due to COVID-19 or had a job offer rescinded or start date for a job delayed due to COVID-19; or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of childcare due to COVID-19, had a reduction in pay (or self-employment income) due to COVID-19, or had a job offer rescinded or start date for a job delayed due to COVID-19; or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.
TDS can only approve the Coronavirus related loan if the loan is taken on or before September 23, 2020.

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

403(b) Plan Sponsor:

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
BEFORE CONTINUING: Please verify that you have selected the correct Employer. If the Employer shown is not correct, please return to the main page and select your correct Employer.

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, Tax Deferred Solutions will process for maximum amount available at the time this form is received in good order.

* Coronavirus Related Loan 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.

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

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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