Bi Weekly Auto Loan Amortization - PDF by mif14341


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									    Loan request form
                                                                                                                                                      For use with:
	                                                                                                                                                Lincoln DirectorSM
                                                                                                                              Lincoln American Legacy Retirement®
    – TPA Serviced

    Participant information
    Our records will be updated to reflect the address given here.

    Plan	name		___________________________________________________________________	Contract	number	____________________

	                                                                              __	Plan	ID	_____________________________
    Account	number		____________________________________________________________                                      __	

    Participant’s	name	_________________________________________________________________________________________________

	   Address	____________________________________________________________________________________________________________

	   City	____________________________________________________________State	________________________	Zip	__________________

	   Social	Security	number		___________-________-_______________			 Date	of	birth	________/_______/_____________	(mm, dd, year)	

	   Daytime	Phone	__________-__________-______________																Date	of	hire	________/_______/_____________		(mm, dd, year)

    Amount and purpose of loan
    •	 Loan	amount	requested	$_______________________

        	 Please	indicate	the	amount	to	be	withdrawn	from	each	source	below.	If	source	selections	are	not	indicated,	we	will	attempt		 	
    	     to	take	money	from	the	salary	deferral	source	first.	If	there	are	not	sufficient	funds	in	the	salary	deferral	source,	The	Lincoln		 	
    	     National	Life	Insurance	Company	(Lincoln)	will	seek	verbal	verification	from	the	Third	Party	Administrator	(TPA)	of	record.	Lincoln		
    	     will	automatically	prorate	the	loan	disbursement	from	all	investment	options.
    	     Salary	Deferral	                        $_________________	                   Prevailing	Wages	                         $_________________	
    	     Employer	                               $_________________	                   ER	Safe	Harbor	Simple	Match	              $_________________
    	     Employer	Discretionary	                 $_________________	                   ER	Safe	Harbor	Non-Elective	              $_________________	            	
    	     Employer	Match	                         $_________________	                   Qualified	Safe	Harbor	Match*	             $_________________
    	     Employer	Secondary	Match	               $_________________	                   Qualified	Safe	Harbor	Non-Elective*	 $_________________

    	     *These sources are applicable to auto-enroll plans with a vesting schedule.
    •	 Purpose of loan 	                c	Purchase	of	principal	residence	
    	 	 	 	                  	          c	Hardship (specify) _________________________________________________________________________
    	 	 	 	                  	          c	Other (specify)	___________________________________________________________________________

    Loan fees
    Your	loan	may	be	tracked	and	administered	by	your	plan’s	TPA	or	by	Lincoln.	For loans tracked by Lincoln,	we	will	charge	the	following	

    	     •	$60.00 initial set-up fee
          •	$30.00 ongoing fee which will be deducted annually on the anniversary date of the contract
          •	Additional loan fees from your plan’s TPA may apply.
    Loan repayment
    Duration	of	loan (years)		c	1	Year					c	2	Years					c	3	Years					c	4	Years                     c	5	Years					
    																																		c	Other	(Applicable only for purchase of primary residence)	__________________________

    Rate	of	interest		_________	%			
    Date	of	first	payment	________/_______/_____________	(Must	be	within	30-day	period	and	must	coincide	with	an	actual	payroll	date.)	

    Repayment frequency:                   c	Weekly	         				c	Bi-weekly												c	Semi-monthly*											c	Monthly	 	                        c	Quarterly

    *	If	semi-monthly,	the	loan	start	date	must	be	the	15th	or	the	30th.
    Repayment of the loan may not exceed five years, unless the loan is for the purchase of a principal residence. If payments are not made at least quarterly,
    the loan is considered in default and the remaining principal balance, plus the interest accrued up to the loan’s default date, will be reported to the IRS as
    taxable income for that year. Loan repayments will be made via payroll deduction.
                                                                                                                            Loan	request	form,	(EM80506-DL-T),	1	of	3
    Payment instructions

	 c	Mail check to the Participant’s address as provided in the Participant Information section.
	 c	Mail check to the Plan Sponsor/Trustee.
	 c	Send funds directly to the participant’s account with the financial institution listed below, via electronic transfer. Your acceptance of the electronic funds
    transfer will constitute your agreement to the terms of the Promissory Note and therefore, your pledge to repay the loan in full, in accordance with the
    amortization schedule.
          (If incomplete or inaccurate information is received, a check will be mailed.)

          	ABA number (nine digit bank routing number; voided check required)________________________________             ____
          Account number________________________________________________________________________________ c Checking                                                                                                 c Savings
          Account owner name _________________________________________________________________________________________________
          Financial institution name ______________________________________________________________________                 ___
                                                                                                           _________________ _____
          Address ___________________________________________________________________________________________________________
          City ____________________________________________________ _____State__________________________ Zip __________________
          Note: If you choose to have your funds sent via electronic transfer, depending on your financial institution, it may take three or four days from our processing date to be received in your account.

    Important information

     Loan requests will be processed within 3 calendar days after Lincoln receives the valid, fully completed loan request form approved by the Trustee of
      the plan.

    For loans tracked by Lincoln,	the	following	is	applicable:
     Once loan proceeds have been disbursed to participant via check or electronic funds, the participant can view the Loan Amortization Schedule, Truth in
      Lending and Promissory Note by visiting

     Hard-copies of the afformentioned documents will be provided to the Plan Sponsor and/or participant by Lincoln.

    Participant and spouse signatures

    If you are married and the vested account balance is $5,000 or more, your spouse’s signature may be required. Please check with your Plan Sponsor/Trustee.
    Form will be returned if appropriate signatures are not present.
    By signing below, you agree that the information above is complete and accurate.
    Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly and willfully presents
    false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
    Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of
    claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits
    a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

    Participant signature_______________________________________________________________________ Date ________/_______/_____________	
    c	Check here if you do not have a living spouse.
    By signing below, you, the spouse, agree and consent to the loan requested.

    Spouse signature (If required)____________________________________________________________  ______ Date ________/_______/_____________
    Witness signature
                                      ________________________________________________________________ Date ________/_______/_____________
    (Plan Sponsor or Notary Public)____

    Notary’s commission expires ________/_______/_____________		(mm, dd, year)
    Plan sponsor authorization

    By signing below, you agree that the information above is complete and accurate . You also direct Lincoln to process the benefit election selected on this form.
    Plan Sponsor/
    Trustee name (print/type)________________________________________________________________________________________________
    Plan Sponsor/
    Trustee signature___________________________________________________________________________ Date ________/_______/____________

                                                                                                                                                                                           Loan	request	form,	(EM80506-DL-T),	2	of	3
Third Party Administrators

This form should be forwarded to your Third Party Administrator (TPA) for review unless other arrangements have been made.

TPA name ________________________________________________TPA representative name __________________________________________________

Phone number ___________________________________________________________________________ Extension__________________________

TPA authorization code______________________________________________________________________ Date ________/_______/____________

Loan	initiation/service	fee	of	$	_______________________ to be paid to the TPA for service fees. (check one)

   c	deducted from the proceeds

   c	in addition to the withdrawal amount

Fees	should	be	sent	to	the	TPA	via:

   c	ACH (if Lincoln Financial Group has previously received ACH instructions)

   c	Check

                                             Lincoln DirectorSM and Lincoln American Legacy Retirement® are group variable annuity contracts issued on contract form #19476 (and variations
                                                 thereof) by The Lincoln National Life Insurance Company, Fort Wayne, IN, and distributed by Lincoln Financial Distributors, Inc. Contractual
                                                                           obligations are backed by the claims-paying ability of The Lincoln National Life Insurance Company.
                                                                                                     Products and features subject to state availability. Limitations and exclusions may apply.
                                                                                            Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates.
                                      Lincoln Financial Group                                          Affiliates are separately responsible for their own financial and contractual obligations.
                                      P. O. Box 2248, Suite 500
                                      Fort Wayne, IN 46801-2248
                                                                                                                                                                 EM80506-DL-T 11/10
                                      800 248-0838
                                                                                                                                             Loan	request	form,	(EM80506-DL-T),	3	of	3

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