Afplanserv 403b Loan Authorization Form printable pdf download

AFPlanServ® 403(b) Loan Approval Form

Participant Instructions

The AFPlanServ 403(b) Loan Approval Form must be submitted to AFPlanServ to approve any 403(b) loan amounts from your

current employer’s 403(b) Plan. The maximum amount that the Plan will permit as a loan is the lesser of (1) 50% of your

vested account balance, or (2) $50,000 reduced by the highest outstanding loan balance of any loan from all Plans held

under the employer in the last 12 months. Your investment provider may require their own paperwork in addition to this form

and may also have additional restrictions on loans. Once you have completed steps 1-5, please return this form to the address at the

bottom of this page

Step 1: Participant Information

Name _________________________________________ Social Security Number __________________ Date of Birth ___/___/___

Mailing Address ______________________________________________________

Home Phone _______________________

City__________________________ State __________________ Zip ____________

Work Phone ________________________

Employer _______________________________________________________________________________________

Step 2: Current and Previous Loans: Please answer the following questions for any 403(b), 401(k), 401(a) or 457(b)

Plans.

Have you ever defaulted on a previous loan(s)? If yes, you must provide documentation that the previously defaulted loan has been

repaid, offset, or otherwise returned to good standing. __ Yes __ No

Do you currently have a loan through your employer’s Plan or have you had in the past 12 months __ Yes __ No

If Yes in #2, what was your total highest loan balance(s) in the last 12 months? $ __________________

Step 3: Current Loan and Account Balance(s): Please identify all your current 403(b), 401(k), 401(a), or 457(b) accounts,

account balances, and loan balance and attach a copy of your most recent account statement(s) for each account.

Investment Provider Name

Current loan balance

Account value (including loan, if applicable)

______________________________________

__________________

__________________________________

______________________________________

__________________

__________________________________

______________________________________

__________________

__________________________________

Step 4: Investment Provider from which 403(b) loan will be established.

Provider __________________________________________________________________________________________________

Account Number ___________________________________________________________________________________________

Step 5: I certify that the information above is correct and request the following loan amount. I understand that the

amount approved may not be available from my account with my investment providers.

___________________________________________________

_______________

$____________________

Participant Signature (Required)

Date

Requested Loan Amount

Please return the approved form to:

Participant

Provider

AFPlanServ Use Only

aximum loan amount approved $________________

______________

___________________________________________________

__________________

AFPlanServ Authorized Signature

Approval Date

Plan #

AFPlanServ®

P.O. Box 269008 · Oklahoma City, OK 73126 · Toll Free 1-866-560-6415 · Fax 1-866-578-0962

AFPS-101

Afplanserv 403b Loan Authorization Form

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