Financial Authorization Request Forms – Alta Montclair TPA Portal

Steps to Receive Transaction Authorization

Download Financial Authorization Request Form – Use this form to request TPA Authorization for Loans, Distributions (including Hardship and Unforeseen Emergency), Rollovers, Transfers, and Exchanges. Fill it out and sign.

Obtain appropriate Form from your Investment Provider (financial company that manages your retirement account), fill it out and sign.

Submit the form and all relevant documents to Alta Montclair – EBSA Plan Administrators for approval (see options on the right).

Alta Montclair-EBSA Plan Administrators will forward approval certificate and all relevant documents to the Investment Provider. Please contact your financial company directly regarding the status of your request.

Options to Submit TPA Authorization Documents

Email your request to tpa@altamontclair.com;

Fax it to 1-408-371-9327 or 1-408-371-9364;

Use the widget below to Upload Required Documents and click on the Request Transaction Authorization button;

Mail documents to
Alta Montclair-EBSA Plan Administrators
901 Campisi Way, Suite 240
Campbell, CA 95008.

Please allow up to five business days to review your request.

Upload Documents and Submit Your Request

Before submitting transaction authorization request, please make sure that you have all documents filled out and signed.

Please use this widget only to submit authorization requests. For all other questions, please visit our Contact us page to submit your inquiry and we’ll get back to you as soon as possible.

While completing Financial Authorization Request Form, please select appropriate Transaction Type:
- If you are requesting funds from your account at the plan defined on this form, select Cash Distribution;
- To move money FROM the plan administered by Atla Montclair-EBSA to another qualified plan (IRA, 401k, etc.) or to purchase Service Credits, select Rollover;
- To move funds from your prior employer TO the plan administered by Alta Montclair-EBSA, select Transfer;
- If you need to exchange Policy/Contract/Account within the same Employer's plan, select Exchange;
- If loans are permitted by your Employer and Investment Provider (Vendor), select Loan.

An IRS-Defined Hardship (403(b) Only) Includes the following types of expenses:
1. Payments for burial or funeral expenses for the employee's deceased parent, spouse, children or dependents
2. Payment for or to obtain medical care for the participant, the participant's spouse, or dependents
3. Costs related to the purchase of a participant's principal residence (not including mortgage payments)
4. Payment of the next 12 months of postsecondary tuition and related educational fees for the participant, the participant's spouse, or dependents
5. Payments necessary to prevent eviction from or foreclosure on a mortgage on the participant's principal residence

Appropriate Hardship Documentation Includes:
- Bills and Receipts from Mortuary, Funeral Parlor
- Medical Bills
- Proof of Home Purchase (Escrow Documents)
- Statement of Expenses from Bursar’s Office
- Notice of Eviction/Foreclosure

An IRS-Defined Unforeseen Emergency (457 Only) Includes the following types of expenses:
1. A severe financial hardship resulting from a sudden and unexpected illness or accident of the participant or a dependent
2. Payments for burial or funeral expenses for the employee's deceased parent, spouse, children or dependents
3. Payments necessary to prevent eviction from or foreclosure on a mortgage on the participant's principal residence
4. A loss of the participant’s property because of a casualty

Appropriate Unforeseen Emergency Documentation Includes:
- Medical Bills demonstrating unexpected illness or accident
- Bills and Receipts from Mortuary, Funeral Parlor
- Notice of Eviction/Foreclosure
- Insurance Report of Casualty Damage due to Natural Disaster and Repair Bills

Download and Submit TPA Financial Authorization Request Forms

Steps to Receive Transaction Authorization

Options to Submit TPA Authorization Documents

Upload Documents and Submit Your Request

Please Choose Correct Transaction Type

Hardship (403b): Eligibility and Required Documentation

Unforeseen Emergency (457b): Eligibility and Required Documentation

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