Fillable LOAN SUSPENSION FORM (DIRECT) (City of Riverside, California)

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LOAN SUSPENSION FORM (DIRECT) (City of Riverside, California)

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47009-0420-CRD20LSNOER | 1
ICMA-RC • Attn: Workow Management Team • P.O. Box 96220 • Washington, DC 20090-6220
toll free 800-669-7400 / for 403(b) plans 833-438-4032 • www.icmarc.org • fax 202-682-6439
e Coronavirus Aid, Relief, and Economic Security (CARES) Act makes available a loan relief provision for participants who
qualify. A qualifying participant is one:
(a) who is diagnosed with coronavirus (COVID-19) by a test approved by the Centers for Disease Control and
Prevention;
(b) whose spouse or dependent is diagnosed with COVID-19 by such a test; or
(c) who experiences adverse nancial consequences as a result of being quarantined, furloughed, or laid o; having
work hours reduced; being unable to work due to lack of child care due to COVID-19; or closing or reducing
hours of a business owned or operated by the individual due to COVID-19.
e CARES Act allows for participants described above to delay the due date for loan repayments due between March 27,
2020 and December 31, 2020 for up to one year and extends the loan repayment period accordingly. If you wish to suspend
your loan repayments, you must complete and submit the enclosed Self-Certication Form stating you qualify for the
loan suspension relief to ICMA-RC along with the Loan Suspension Form.
Please follow the steps shown below to ensure ICMA-RC can process your request in a timely manner. is form is used to
request a loan suspension for up to one year covered by the CARES Act Loan Suspension Relief.
1. Complete BOTH the Self-Certication Form and Loan Suspension Form and return to ICMA-RC.
2. If your loan repayments are currently made through payroll deduction, send a copy of the loan suspension
form to your Plan Sponsor for processing; otherwise, your loan repayments might continue.
3. If your loan repayments are currently made through Automated Clearing House (ACH) bank draft, you do not
need to notify your plan sponsor. ICMA-RC will suspend your ACH loan repayments.
Please keep a copy of the completed forms for your records.
TIME FRAME FOR PROCESSING CORONAVIRUS-RELATED LOAN SUSPENSION REQUESTS
Following the receipt of your properly completed Loan Suspension Form and Self-Certication Form from your plan sponsor,
ICMA-RC will process loan suspension requests as soon as possible (typically within seven to 10 business days).
At ICMA-RC, we take security of our account holders retirement assets seriously. We have security measures in place and
we continuously apply enhancements to safeguard your assets.
Additional care is taken regarding the security of your account when processing withdrawal requests. Adding or
changing personally identiable information on le with ICMA-RC may delay your withdrawal.
LOAN SUSPENSION FORM (DIRECT)
CORONAVIRUS AID, RELIEF, AND ECONOMIC SECURITY (CARES) ACT
47009-0420-CRD20LSNOER | 2
ICMA-RC • Attn: Workow Management Team • P.O. Box 96220 • Washington, DC 20090-6220
toll free 800-669-7400 / for 403(b) plans 833-438-4032 • www.icmarc.org • fax 202-682-6439
EMPLOYER PLAN NUMBER: ___ ___ ___ ___ ___ ___
I, _______________________________ (participant name), have requested a Coronavirus-Related Loan Suspension from the above plan. To be
eligible for the Coronavirus-Related loan suspension, I hereby certify that I meet one of the following criteria:
ØI have been diagnosed with the virus SARS-CoV-2 or with coronavirus (COVID-19) by a test approved by the Centers for Disease Control and
Prevention.
ØMy spouse or dependent (as dened in Code section 152) is diagnosed with such virus or disease.
ØI have experienced adverse nancial consequences as a result of being quarantined, furloughed, laid off, having work hours reduced due to such
virus or disease, being unable to work due to lack of child care due to such virus or disease, or other factors as determined by the Secretary of the
Treasury.
I make this certication on this day, ____/____ /_____ (MM/DD/YYYY)
Signature: ____________________________________________________________________________
Printed Name: _________________________________________________________________________
RETURN THIS FORM ALONG WITH THE LOAN SUSPENSION REQUEST FORM TO ICMA-RC. IF YOUR LOAN REPAYMENTS ARE CURRENTLY MADE
THROUGH PAYROLL DEDUCTIONS, SEND A COPY OF THE LOAN SUSPENSION FORM TO YOUR PLAN SPONSOR FOR PROCESSING;
OTHERWISE, YOUR LOAN REPAYMENTS MIGHT CONTINUE. IF YOUR LOAN REPAYMENTS ARE CURRENTLY MADE THROUGH ACH BANK DRAFT, YOU DO
NOT NEED TO NOTIFY YOUR PLAN SPONSOR. ICMA-RC WILL SUSPEND YOUR ACH LOAN REPAYMENTS.
SELF-CERTIFICATION FORM
CORONAVIRUS-RELATED LOAN SUSPENSION ELIGIBILITY (required)
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47009-0420-CRD20LSNOER | 3
ICMA-RC • Attn: Workow Management Team • P.O. Box 96220 • Washington, DC 20090-6220
toll free 800-669-7400 / for 403(b) plans 833-438-4032 • www.icmarc.org • fax 202-682-6439
Employer Plan Number: ___ ___ ___ ___ ___ ___ Employer Plan Name: ____________________________________________
Loan Number: _____________
Full Name: ____________________________________________________________________________
Mailing Address: _______________________________________________________________________
Date of Birth:
/ / (mm/dd/yyyy) Social Security Number: – –
Preferred Phone Number: ( ) – Email Address: ________________________________________
I hereby elect to suspend my loan payment effective on the following date: / / 2020
I elect to have the loan repayment schedule restart on / / . I understand this date can be no later than 12 months
from the above effective date.
Note – If no restart date is provided, ICMA-RC will restart your repayments 12 months from the above suspension date.
Please note the following:
• Interest will continue to accrue.
• Re-amortization may be needed when loan repayments begin again to include the accrued interest amount, or you will be required to pay the accrued
interest in a lump sum payment to bring the loan to a current status.
I acknowledge I have received, read, and signed the Coronavirus-Related Loan Suspension Self-Certication Notice. I direct ICMA-RC to process the request
indicated above. As required by law, and under the penalty of perjury, I certify that the Social Security Number (Taxpayer Identication Number) I provided is
correct.
Participant Signature: _______________________________________________________________
Print Name: ___________________________________________________________________________
Date:
/ / (mm/dd/yyyy)
RETURN THIS FORM ALONG WITH THE LOAN SUSPENSION REQUEST FORM TO ICMA-RC. IF YOUR LOAN REPAYMENTS ARE CURRENTLY MADE
THROUGH PAYROLL DEDUCTIONS, SEND A COPY OF THE LOAN SUSPENSION FORM TO YOUR PLAN SPONSOR FOR PROCESSING;
OTHERWISE, YOUR LOAN REPAYMENTS MIGHT CONTINUE. IF YOUR LOAN REPAYMENTS ARE CURRENTLY MADE THROUGH ACH BANK DRAFT, YOU DO
NOT NEED TO NOTIFY YOUR PLAN SPONSOR. ICMA-RC WILL SUSPEND YOUR ACH LOAN REPAYMENTS.
1
ACCOUNT HOLDER INFORMATION
LOAN SUSPENSION FORM (DIRECT)
CORONAVIRUS-RELATED LOAN SUSPENSION ELIGIBILITY (required)
2
LOAN SUSPENSION REQUEST (all elds are required)
3
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LOAN SUSPENSION FORM (DIRECT) (City of Riverside, California)

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Completed 4 August 2020

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