MUTUAL457
#10520 (11/7/2012)
(Mutual of Omaha)
CUYAHOGA COUNTY PUBLIC EE'S DEF COMP PLAN
215467
Loan Payment/Payoff Transmittal Form
This form is to be used for all non-payroll related loan payoffs. Receipt of this form in “good” order
will enable your loan payoff to be processed in an accurate and timely manner. Loan payments/payoffs
submitted which are not accompanied by a properly completed form may result in processing delays
or the request may be returned to you unprocessed.
PARTICIPANT
INFORMATION
Social Security Number ________________________________________________________________________________________________
LOAN
INFORMATION
Please check whether you are submitting a Loan Payment or a Loan Payoff.
First Name ______________________________________________ Last Name__________________________________________________
Loan Payment (41)
Loan Payoff (42)
Loan Number _____________________________________________________________________
Dollar Amount of Check ___________________________________________________________
Date Sent to Trust (mmddyyyy) _____________________________________________________
Submitted By:
Name ____________________________________________________________________________ Date _____________________________
1. If you are paying off the loan in full, you must notify your plan administrator or payroll coordinator to discontinue loan
payment withholding from your wages as soon as possible.
2. Please fax your completed Loan Payment/Payoff Transmittal form to Mutual of Omaha Retirement Services at (218) 855-6010,
Attn: Contribution Processing or mail it to Mutual of Omaha Retirement Services at:
Mutual of Omaha Retirement Services
Attn: Contribution Processing
124 Eighth Avenue NE
Brainerd, MN 56401
3. Mail a copy of your completed Loan Payment/Payoff Transmittal Form and original check made payable to MG Trust
Company, LLC to:
MG Trust Company, LLC
Attn: Trust Services
REF: TPA #000142
PO Box 46546
Denver, CO 80201
Overnight Address
MG Trust Company, LLC
Attn: Trust Services
REF: TPA #000142
717 17th Street, Suite 1300
Denver, CO 80202
Please include your client number on your check. If more than one loan payment/payoff is being sent, please use a separate
Loan Payment/Payoff Transmittal form for each request.
NOTE: The loan payoff amount is good for 10 business days from the day that the payoff amount was obtained from a service representative
or from the website. If a check is received beyond 10 business days, the additional accumulated interest will be due.
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