Fillable Request For Loan (Page 2 of 3) in pdf

SECTION 3: ELECTRONIC FUND TRANSFER

Completed by PARTICIPANT

Only offered for plans with Guardian (greater than $5,000), ING, John Hancock and Nationwide

Please submit a copy of a voided check for all EFT requests

Account #__________________________________

Routing #_______________________________________

Exact name as it appears on bank account _____________________________________________________________

(Participant must be single or joint owner of account)

Bank Account Type:

Checking

Savings

Bank Name: ____________________________________________________________________________________

Address: _______________________________________________________________________________________

City: __________________________________ State: __________ Zip: __________ Phone: ____________________

If this section is not fully completed, a check will be issued.

SECTION 4: REQUIRED SIGNATURES

Completed for ALL loan requests

I request to borrow the loan amount listed above from the Plan, based on terms specified above. I understand that my

request for a Plan loan is subject to review by the Plan Administrator and must meet the requirements outlined in the Plan

Document and Participant Loan Program in order for a loan to be granted. I certify that the statements on this application

are correct and complete. If any statement proves false, the Plan may declare my indebtedness immediately due.

I have read and understand the Request for Loan Instructions for this form. I understand that up to 50% of my vested

interest under the Plan will be used as security for the loan and that I, and if required my spouse, will need to sign an

irrevocable pledge and assignment of such interest under the Plan prior to any loan being granted. I understand that my

may result in the loan being in

failure to repay this loan when due or failure to pay any scheduled payment when due

default

. Should my employment terminate with the employer for any reason while this obligation is unpaid and under

circumstances in which the Plan Administrator would ordinarily make a distribution from the Plan to me or to my named

beneficiary, I authorize the reduction of the amount otherwise distributable to me, or to my named beneficiary, by this

outstanding indebtedness, together with any accrued interest due on the indebtedness.

I understand that, in addition to the required processing fee, the Plan’s investment manager may impose a charge to

complete this loan request and/or may restrict the completion of all or a portion of this loan request.

_________________________________________________________________

_____________________

Participant Signature

Date

_________________________________________________________________

_____________________

Plan Administrator Signature

Date

If the Plan does not have annuity provisions and/or the participant is not married, please check here:

SPOUSAL CONSENT IS NOT APPLICABLE

If the plan has annuity provisions and the participant is married, spousal consent must be given below:

Spousal Consent:

I hereby voluntarily and irrevocably consent to the loan amount requested above and to the above pledge

of my spouse’s vested interest under the Plan as security (or collateral) for the loan. I understand that by

consenting to this loan, any benefit that may be payable to me as beneficiary (if I am the beneficiary) will

be reduced by the outstanding balance (unpaid principal and accrued interest) on the loan.

__________________________________________________________

______________________

Spouse Signature

Date

Witnessed by:

__________________________________________________________

______________________

[ ] Notary Public Signature & Seal OR [ ] Plan Administrator Signature

Date

8/12

Page 2 of 3

Request for Loan Form

(Complete All Pages)

Request For Loan Page 2

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