Loan Request Form
Name:____________________________________________________________ ___________________________
Last First Middle Initial Social Security Number
Marital Status: Married Email Address:_________________________________________________________
Not Married Contact Number(s): _____________________________________________________
A. LOAN DETAILS
1. This is a request to borrow $______________________ from my NMI Retirement Fund 401(a) Defined Contribution Plan. If this amount is
more than the maximum available to me, I request a loan for the maximum amount available (minimum of $1,000).
2. The purpose of this loan is:
Personal (maximum term: 60 months). OR To acquire my primary residence (maximum term: 360 months).
3. I want to repay the loan in equal installments over a term of ____________ months / years / ______ payments (circle one).
I understand that: (1) Plan loans will be repaid through regular payroll deductions as long as there is a loan balance in my account; (2) the loan interest rate is at the prime interst rate plus 1%, (3)
when the loan is authorized, I will receive a check and Truth-in-Lending Disclosure Statement/Promissory Note detailing the terms of the loan; (4) by signing the Truth-in-Lending Disclosure
Statement, I agree in full to the terms and conditions of the Promissory Note; (5) if the terms and conditions of the loan are not acceptable to me, I will return the loan check and all
documentation to ASC Trust, and the money will be returned to my account; (6) loan prepayment, in part or in full, is permitted at any time; (7) any unpaid balance is due on the day my
employment ends and may be taxable if not repaid at that time; (8) the loan will be funded through withdrawals from my applicable contribution accounts, divided proportionately among my
investment funds; (9) my loan payment will be reinvested according to my fund selections at the time the payment is received; (10) I will be charged interest on the outstanding principal balance;
(11) a one-time loan setup fee of $100.00 will be charged against my loan; (12) there is quarterly loan maintenance fee of $15.00.
B. PARTICIPANT SIGNATURE
C. SPOUSAL CONSENT AND WITNESS TO SPOUSAL CONSENT
Spousal Consent: By signing below, I consent to the loan requested by my spouse. I understand that this loan is secured by my spouse's vested interest in the Plan, and that by signing, I may be
waiving my right to Plan benefits.
______________________________________________ __________________________________________ _____/_____/_____
Spouse Signature Spouse Name (print) Date
Witness to Spousal Consent: I have witnessed the signature of the person who signed this form as spouse on the date indicated above. This person presented satisfactory evidence
to prove his/her identity.
Plan Representative________________________________________ (or) Notary Public _______________________________________
Date _____/_____/_____
State __________________________________ County ____________________________
In addition to signing here, notaries may attach a standard form of acknowledgment if they wish.
PLAN ADMINISTRATOR USE ONLY
I have reviewed this loan request and certify that it conforms to the terms of the Plan. ASC Trust is authorized to comply with this request by (1) preparing the loan documents for the
participant's execution and (2) issuing, or instructing the fund manager to issue a check representing the loan proceeds. The company will initiate payroll deductions as detailed on the
Loan Summary Report. I direct ASC Trust to set up a loan repayment schedule.
Plan Administrator's Signature: __________________________________________________________ Date: _____/_____/_____
EFF REV 06.2019
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ASC Trust, Guam Office
120 Father Dueñas Ave, Ste. 110,
Hagåtña, Guam 96910
Phone: (671) 477-2724 * Fax: (671) 477-2729
info@asctrust.com * www.asctrust.com
ASC Trust, Saipan Office
P.O. Box 10001, PMB 201, Saipan, MP. 96950
3rd Floor, TSL Plaza, Beach Road Garapan, Saipan
Tel: (670) 235-2724/5 * Fax: (670) 235-2729
www.asctrust.com
A valid photo ID must be attached to this request.
NORTHERN MARIANA ISLANDS RETIREMENT FUND
401(A) DEFINED CONTRIBUTION SYSTEM
AGENCY NAME: __
_________________________________________________________________________________________
By signing this form, I authorize implementation of the above loan instructions.
Participant Signature _
______________________________________________________ Date_____/_____/_____
Plan Representative/Notary as Witness to Participant Signature______________________________________________ Date______/______/_______
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