EQUI-VEST®

FORM # NJ992–3114 E6247

Page 1 of 6 (1/2024)

The following information is required by Equitable Financial Life Insurance Company (“Equitable”) in order to process a loan against your

EQUI-VEST Certicate indicated on this form. Before you complete this form, you should review the entire form, including the information

following the authorized signatures. You may need to check your records or to request information from your Employer to conrm the

information needed to process your loan request. You should also consult your own attorney, accountant or tax advisor for tax information

relating to your own particular situation.

This Loan Request Form is entered into between you and the Plan indicated on this form. Equitable will perform certain services with respect

to the loan on behalf of the Employer. Equitable is not responsible for monitoring compliance with applicable law or the terms of the Plan.

If you have separated from service within The State of New Jersey Retirement Program, The State of New Jersey will not authorize your

loan request.

1. PARTICIPANT INFORMATION (Certicate number must be provided to process this request.)

Check appropriate program for the certicate listed below:

❏ 403(b) ACTS ❏ 401(a) (ABP)*

NAME (Last Name, First Name, Middle Initial) CERTIFICATE NUMBER

SOCIAL SECURITY NUMBER NAME OF EMPLOYER/PLAN NAME

ADDRESS UNIT NUMBER (IF KNOWN)

CITY/STATE/ZIP CODE FINANCIAL PROFESSIONAL

DAYTIME PHONE NUMBER MOBILE PHONE NUMBER EMAIL ADDRESS

DATE OF HIRE

Are you immediately vested? ❏ Yes ❏ No If no, please indicate your date of hire as the Vesting

Start Date:

* Loans are not available in the 1st year, unless fully vested.

❏ Please check if this is an Address Change ❏ Please check if this is an Email Change

2. LOAN AMOUNT REQUESTED:

Subject to the employer’s plan, the minimum loan amount allowed with respect to this contract is $1,000; the vested Annuity

Account Value must be at least $2,000. The amount you may borrow is based upon your Certicate’s vested Annuity Account

Value on the Loan Effective Date, as dened in Section 9. Except as otherwise explained below, the maximum loan allowed

is 50% of the vested Annuity Account Value, but not more than $50,000.

Please CHECK and COMPLETE either A, B or C below for desired action (if no selection is made, the loan will

default to the maximum available):

❏ A. I request the maximum loan amount to be established proportionately from all Funds of the vested Annuity Account

Value. I represent that this is the only account I have under all plans of my employer. (Your Employer’s plan may not

allow this option. Please check with your Employer prior to completing this loan request form.)

❏ B. I request a loan amount of $____________ to be established proportionately from all Funds of the vested Annuity Account Value.

❏ C. I request a loan amount of $_____________ to be established from my Funds of the vested Annuity Account Value as

indicated in the Loan Funding Schedule in Section 5 below.

EQUI-VEST

LOAN REQUEST FORM FOR THE

STATE OF NEW JERSEY ALTERNATE

BENEFITS AND ADDITIONAL

CONTRIBUTIONS TAX SHELTERED

PROGRAMS

Express Mail:

Equitable

EQUI-VEST

Processing Ofce

8501 IBM Dr., Suite 150-GR

Charlotte, NC 28262-4333

Regular Mail:

Equitable

EQUI-VEST

Processing Ofce

PO Box 1430

Charlotte, NC 28201-1430

Fax Number:

(816) 701-4969

For Assistance: Call (800) 628-6673

Monday − Thursday

8:00 a.m. − 7:00 p.m. EST

Friday 8:00 a.m. − 5:00 p.m. EST

www.equitable.com

Current Online Transactions: Address Changes, Allocation Changes, Dollar Cost

Averaging Set Ups, Inquiries, Systematic Asset Rebalancing, Transfers, Loan Payments

FORM # NJ992–3114 E6247

Page 2 of 6 (1/2024)

3. I REQUEST A LOAN TERM OF: ❏ 5 years

(Check One. If no election is made, ❏ 10 years. I represent that these loan funds will be used to acquire a dwelling unit

the default will be 5 years) that will, within a reasonable time, be used as my principal residence.

4. LOAN INTEREST RATE:

*Loan Interest __________% (Must be completed by Employer as described above).

*Unless otherwise stated by your employer, the loan interest will be calculated at an annual rate of 6%.

5. LOAN FUNDING SCHEDULE:

You have the option to request that your loan be established, and the Loan Reserve Account be funded, from specic

Investment Options rather than proportionately from all Investment Options in which you participate. If you wish to specify

a manner in which the loan is to be established, you must complete the information below. However, before proceeding,

please take note of the following:

1. Any Investment Option transfers you may request after completion of this schedule and before we process your loan

application may impact your instructions.

2. If you specify dollar amounts for the establishment of the loan, keep in mind that the Loan Reserve Account must be

funded with 110% of the amount you indicate.

3. The dollar value of your participation in the Variable Investment Options uctuates daily and may increase or decrease;

therefore, an adequate margin should be allowed for such uctuations.

Please indicate the amount that you wish to have taken from each investment option to fund this loan, subject to

the restrictions indicated below. Loans are not permitted on amounts invested in the Fixed Maturity Options (FMOs).

❏ Prorate my requested loan amount proportionately from all investment options if my selections below are not sufcient.

❏ Limit my loan amount if selected investment options are insufcient.

$______ 1290 VT GAMCO Small Company Value (37*)

$______ 1290 VT SmartBeta Equity ESG (9C*)

$______ 1290 VT Socially Responsible (92*)

$______ EQ/400 Managed Volatility (7L*)

$______ EQ/AB Small Cap Growth (TP*)

$______ EQ/Aggressive Allocation (18*)

$______ EQ/American Century Mid Cap Value (9J*)

$______ EQ/Balanced Strategy (8Q*)

$______ EQ/ClearBridge Select Equity Managed Volatility (6F*)

$______ EQ/Common Stock Index (T1*)

$______ EQ/Conservative Allocation (15*)

$______ EQ/Core Bond Index (96*)

$______ EQ/Core Plus Bond (TH*)

$______ EQ/Emerging Markets Equity PLUS (8W*)

$______ EQ/Equity 500 Index (TE*)

$______ EQ/Fidelity Institutional AM

Large Cap (9K*)

$______ EQ/International Core Managed Volatility (88*)

$______ EQ/International Equity Index (TN*)

$______ EQ/International Value Managed Volatility (73*)

$______ EQ/Invesco Global (6A*)

$______ EQ/Invesco Global Real Assets (9M*)

$______ EQ/Janus Enterprise (08*)

$______ EQ/JPMorgan Value Opportunities (72*)

$______ EQ/JPMorgan Growth Stock (32*)

$______ EQ/Large Cap Growth Index (82*)

2. LOAN AMOUNT REQUESTED: (cont’d)

By signing this form, I indicate that I have not defaulted on any loans from this or any other plan of my employer. If

I have defaulted on such a loan, I have included the sum of the unpaid balance and continually accruing interest on

the loan in my calculation of “outstanding loan balance;” see Item 15, (B) Maximum Loan Amount. Further, I represent

that this loan is within the maximum loan amount permitted under Internal Revenue Code as described in Section 15. The

total of the loan amount requested above, when aggregated with loans (principal plus interest) from all qualied plans of my

Employer, including for example any Internal Revenue Code 403(b) and 401(a) arrangements funded by my Employer and

Internal Revenue Code Section 457(b) plans, does not exceed the greater of $10,000 or 50% of the value of nonforfeitable

accrued benets under all of my Employer’s qualied plans, including this and other 403(b), 401(a) and 457(b) plans. (For

my EQUI-VEST Certicate funding this 403(b) or 401(a) plan, my nonforfeitable accrued benet includes my vested Annuity

Account Value. For other plans of my Employer, it is my vested benet.) In no event can the loan exceed $50,000, reduced by

the excess of the highest outstanding balance of all loans from my Employer’s qualied plans as well as other 403(b), 401(a)

and/or 457(b) plans that I may participate in during the one-year period ending on the day before the date the loan is made,

less the outstanding balance of all loans from all such plans on the date the loan is made. In addition, because ERISA rules

do not permit more than 50% of the present value of a plan participant’s vested accrued benet under the plan to be used

as security for the outstanding balance of all plan loans, the maximum amount of your loan may be less than 50% of my

vested Annuity Account Value.We may also require that you elect not to have income tax withholding apply with respect to

any interest and/or loan principal that would otherwise be subject to withholding.

FORM # NJ992–3114 E6247

Page 3 of 6 (1/2024)

5. LOAN FUNDING SCHEDULE: (cont’d)

* The number in parentheses is shown for internal use only.

7. REALLOCATION OF LOAN REPAYMENT

Your loan payments are currently allocated to the Guaranteed Interest Option (GIO). They remain there unless you choose

to reallocate how these amounts are invested. If you wish to have your loan payments transferred to your current allocation

percentages on le with us on the following business day, check the box below.

I elect to:

q Establish the Reallocation of Loan Payment

6. DELIVERY OPTIONS

Please select only one option for how you would like your payment sent. If you do not complete this section, we will default

to the address of record and send you a check VIA rst class mail.

❏ First Class Mail No Fee – Please allow 5 - 10 business day for delivery of your check

❏ Direct Deposit No Fee – Please allow 5 - 7 business days for delivery. You must attach a voided personal check for

Direct Deposit requests. We cannot process your requested delivery option without it. Direct Deposit forms are

not acceptable.

❏ Express Delivery $35 Fee – Please allow 3 - 5 business days for delivery of your check

❏ Wire Transfer $90 Fee – Please allow 2 - 4 business days for delivery of your funds. Only available for wires

amounts of $10,000.00 or more. You must attach a voided personal check for Wire Transfer requests. We cannot

process your requested delivery option without it. Direct Deposit forms are not acceptable.

PLEASE NOTE: IF WE ARE UNABLE TO VERIFY THE BANK ACCOUNT INFORMATION BASED ON THE

INFORMATION YOU PROVIDED, A CHECK WILL BE MAILED TO YOUR ADDRESS OF RECORD VIA FIRST CLASS

MAIL.

❏ This bank account has been previously used by me to electronically receive funds from Equitable. I acknowledge that

for my own security, if this cannot be veried, a check payable to me will be mailed to my address of record.

❏ This bank account has not been used previously for electronic transfer of funds with Equitable. I acknowledge that for

my own security, Equitable will attempt to validate the bank account, and if this cannot be veried, a check payable to

me will be mailed to my address of record.

$______ EQ/Large Cap Value Managed Volatility (89*)

$______ EQ/Loomis Sayles Growth (34*)

$______ EQ/MFS International Growth (26*)

$______ EQ/MFS Mid Cap Growth Focused Growth (9P*)

$______ EQ/MFS Technology (9S*)

$______ EQ/MFS Utilities Series (9T*)

$______ EQ/Mid Cap Index (55*)

$______ EQ/Moderate Allocation (T4*)

$______ EQ/Money Market (T3*)

$______ EQ/Morgan Stanley Small Cap Growth (9Y*)

$______ EQ/PIMCO Global Real Return (8Y*)

$______ EQ/PIMCO Ultra Short Bond (28*)

$______ EQ/Small Company Index (97*)

$______ EQ/Wellington Energy (9O*)

$______ American Funds Insurance Series

The Bond Fund of America (8V*)

$______ Delaware Ivy VIP High Income (8G*)

$______ Guaranteed Interest Option (A1*)

$______ Multimanager Aggressive Equity (T2*)

$______ Multimanager Core Bond (69*)

$______ Segment Holding Account for S&P 500 1 yr

-10% Buffer (V1*)

$______ Structured Investment Option S&P 500 1 yr

-10% Buffer (V2*)

$______ Target 2015 Allocation (6G*)

$______ Target 2025 Allocation (6H*)

$______ Target 2035 Allocation (6I*)

$______ Target 2045 Allocation (6J*)

$______ Target 2055 Allocation (8Z*)

$______ VanEck VIP Global Resources (8N*)

FORM # NJ992–3114 E6247

Page 4 of 6 (1/2024)

9. PARTICIPANT AUTHORIZATION: I have read and do understand the terms of this Loan Request Form including those

on the reverse side of this form and the formula for computing the maximum loan amount. I acknowledge that any loan

not in accordance with the requirements outlined herein may be considered as taxable income to me. I am returning the

original and making a copy for my records, as this Loan Request Form together with the Loan Conrmation Notice

comprises the Loan Agreement.

For your protection, California law requires the following to appear on this form. Any person who knowingly presents false

or fraudulent information to obtain or amend insurance coverage or to make a claim for the payment of a loss is guilty of a

crime and may be subject to nes and connement in state prison.

_________________________________________________________ ________________________________________

Signature of Participant (electronic signature is not acceptable) Date

If you have separated from service within The State of New Jersey Retirement Program, The State of New Jersey will not

authorize your loan request.

8. AUTOMATIC REPAYMENT OPTION This option permits you to have your loan repayments automatically deducted from your

checking account. If you select this option, a voided check is required. We cannot process your request without it. Direct Deposit

Forms or Deposit Slips are not acceptable.

q Monthly - Your quarterly repayment amount will be divided into 3 monthly installments and drafted from your account 3

business days prior to the monthly due date.

q Quarterly - Your full quarterly payment will be drafted from your bank account 3 business days prior to the quarterly due date.

10. EMPLOYER AUTHORIZATION: As the authorized person for the local Employer of the participant identied in Section

1, the Employer authorizes the participant’s request for a loan as permitted under the NJ ACTS and/or ABP Program

sponsored by the NJ Division of Pensions and Benets.

_________________________________________________________ ________________________________________

Authorized Signature of Employer Date

_________________________________________________________ ________________________________________

Print Name Print Title

FORM # NJ992–3114 E6247

Page 5 of 6 (1/2024)

TERMS AND CONDITIONS (please retain for your records)

1. LOAN RESERVE ACCOUNT: On the Loan Effective Date (dened in Section 2 below), we will hold in reserve an amount

equal to the loan amount, which will earn interest at the “Loan Reserve Account Rate” (dened in Section 4 below) during

the loan term, plus 10% of the loan amount, which will earn interest at the Guaranteed Interest Rate, as dened in the

Certicate. This loan reserve will remain in your Certicate and will be reported on all nancial conrmation notices sent to

you. You may not make any partial withdrawals or transfers from the Loan Reserve Account until after repayment. You may

specify on your Loan Request Form from which Investment Option(s) the Loan Reserve Account will be funded (see Section

5, Loan Funding Schedule listed above).

2. LOAN EFFECTIVE DATE: If the loan request form is received prior to the 27th day of the month, this transaction will be

effective on the day on which the loan request form, properly completed, signed and in good order, is approved at our

Processing Ofce (see addresses shown on cover). If the loan request form is received on the 27th day of the month or later,

this transaction will be effective on the rst business day of the month following the date on which the loan form, properly

completed signed and in good order, is approved at our Processing Ofce. A separate Conrmation Notice is issued for loans. If

you do not receive a Conrmation Notice or check within 10 days, please notify the EQUI-VEST Processing Ofce immediately. A

loan does not affect future contributions. Any properly completed and signed form received in Equitable’s EQUI-VEST Processing

Ofce after 4:00 PM Eastern Time or after an early close of regular trading on the NYSE, will be effective the next business day.

3. LOAN TERM: The repayment period is 5 years. The only exception is if you use the loan funds to acquire a dwelling unit

which, within a reasonable time, is to be used as your principal residence. In that case, the loan repayment period is 10

years. In requesting a 10-year loan term, you specically represent that you will use the loan funds for this purpose.

4. LOAN RESERVE ACCOUNT RATE: The Loan Interest Rate in Section 4 minus 2%.

5. LOAN REPAYMENT: Your initial Loan Conrmation Notice will indicate the amount of principal you have borrowed and the

interest you must repay quarterly over the specied loan term. It will also specify the loan repayment dates. Upon request, we

will send you an amortization schedule. Your rst payment is due the rst day of the third month following the Loan Effective

Date. Approximately 30 days before each payment due date, we will send you a Loan Payment Notice which will indicate the

amount due and the remaining unpaid principal balance unless you have elected the systematic repayment option. Payment

must be made by money order or bank check for full loan repayment, or personal check for ongoing quarterly payments.

All payments made by check must be drawn on a bank in the U.S., in U.S. dollars and made payable to Equitable. All

checks are accepted subject to collection. Any payments will rst be applied by us to interest due, with the balance applied

towards repayment of the loan principal. Please note: allow 8 business days for processing on personal checks. We send a

Conrmation Notice after we receive your loan repayment.

Your loan may be repaid in full at any time (by bank check or money order only), including interest due. After any

repayment is made, including full repayment of the loan, the principal amount repaid will be transferred from the Loan

Reserve Account to the Guaranteed Interest Option and may be withdrawn (if otherwise permitted), transferred to another

Investment Option, or applied to a Benet payment as described in the Certicate.

For your protection, California law requires the following to appear on this form. Any person who knowingly presents false or

fraudulent information to obtain or amend insurance coverage or to make a claim for the payment of a loss is guilty of a crime

and may be subject to nes and connement in state prison.

Mail quarterly and full loan payments to:

Regular Mail

EQUITABLE EQUI-VEST Loan Payment Lockbox

PO Box 13569

Newark, NJ 07188

Electronically:

Log onto www.equitable.com

Repaying is quick, easy and secure

Express Mail

Equitable

EQUI-VEST

Processing Ofce

8501 IBM Dr., Suite 150-GR

Charlotte, NC 28262-4333

Required repayment of the loan may be accelerated and full repayment of unpaid principal and interest will be required

when your Contract terminates. The following transactions will terminate your Contract: 1) death, 2) commencement of

Benets under the contract, and 3) other termination of the Certicate (for example, a surrender). Please note, we reserve

the right to limit transfers of Cash Value, up to the amount remaining in your Loan Reserve Account under your Certicate, to

another 403(b) or 401(a) arrangement while you have an outstanding loan. We also have the right to accelerate the repayment

of this loan if we determine that such acceleration is necessary to preserve the federal income tax status of your Certicate.

6. DEFAULTS: By each due date, if the amount of the loan payment is less than the amount then due or the loan payment

is not received at the EQUI-VEST Processing Ofce, we will treat the unpaid balance of the loan at that time, including

interest due but not paid, as a deemed distribution for Federal income tax purposes. In determining the due date, we will

apply the applicable IRS rules for a grace period. We will withdraw the amount of such entire unpaid balance from your Loan

Reserve Account. Even if a loan has been defaulted for tax purposes as described in this section, Equitable has the right

to foreclose on the defaulted unpaid balance, plus interest to the date of foreclosure, after the time that amounts under this

Certicate are no longer subject to any withdrawal restrictions which may apply under the Plan or Internal Revenue Code.

FORM # NJ992–3114 E6247

Page 6 of 6 (1/2024)

TERMS AND CONDITIONS (cont’d)

7. NUMBER OF LOANS: Only one loan is permitted on your Certicate at one time. Should you require additional funds

while any portion of a prior loan remains outstanding, the existing rst loan must be fully repaid, including all interest due.

After full repayment is conrmed, you may request a new loan in the desired amount but the new loan will be subject to

the limitations discussed on the front of this form with respect to the maximum loan amount, including the limitation with

respect to prior outstanding loan balances during the one-year period ending the day before the new loan is made. We

reserve the right not to permit new loans if a previous loan was defaulted and not repaid when due.

8. MAXIMUM LOAN AMOUNT:

The maximum loan amount you are permitted is calculated as follows:

(A) Is the loan amount you have indicated in Section 2.

(B) Is the outstanding loan balance on all other loans you have not yet repaid from all other qualied plans, funded by the

Employer who has provided the funds for this contract, including for example other Internal Revenue Code Section

403(b) or 401(a) Plans or Internal Revenue Code Section 457 EDC plans.

(C) Is the amount of your highest outstanding balance for the one year period ending on the day before the date this loan

is made for all the loans from this Employer’s plans, including those you have repaid.

(D) Is (C) minus (B).

(E) If (D) is positive, then subtract (D) from $50,000 to calculate the value of (E). If (D) is negative or equal to zero, then (E) is

equal to $50,000.

(F) Determine the present value of your “nonforfeitable accrued benets” under all of your Employer’s qualied plans,

including this Certicate. For this Certicate the benet is equal to the vested Annuity Account Value. Under all of your

Employer’s qualied plans it is equal to your vested benet. Divide this number by 2.

(G) Is the greater of (F) and $10,000.

(H) Is the lesser of (E) and (G).

(I) Is (A) plus (B).

(J) Your maximum loan amount is the lesser of (H) and (I).

9. AUTOMATIC PAYMENT OPTION



Your institution will debit the necessary amount from your checking account and transfer it to Equitable.



You can discontinue this program at any time by sending us a written request.

10. REALLOCATION OF LOAN PAYMENT

 Please note, no transfer will occur if the balance in GIO is not 110% of the loan balance.

Additional Information



The owner’s name on the contract must be the same as the owner of the bank/nancial institution account.



Your bank or nancial institution may take 2 or more business days to deposit the funds into your account.



Keep in mind that in order to take advantage of direct deposit, your nancial institution MUST be a participating member

of the AUTOMATED CLEARING HOUSE (ACH) Association.

Direct Deposit Agreement

By my signature in Section 9 I consent to the following:



I certify that the bank routing number and bank account number provided are accurate. I understand that I should certify

these with my bank or nancial institution prior to submitting the form to ensure that I have the correct information for direct

deposit. Incorrect information may misdirect and/or delay receipt of my funds.



I certify that the above account(s) bears my name, that I am an unrestricted and authorized signer for each account and

that the funds are being deposited to a nancial institution within the U.S. and will remain in a U.S. Bank. The funds will not

be credited further to an international bank.



I hereby authorize Equitable to directly deposit the amount of my loan in the account listed above at the above named bank/

nancial institution. This authorization will become effect only upon acceptance by Equitable. This agreement will remain in

full force and effect until Equitable has received written notication from me of its termination in such time and in such manner

as to afford Equitable and my bank or nancial institution a reasonable opportunity to act on it.



In the event that Equitable noties the nancial institution that funds to which I am not entitled have been deposited to my

account, in error, I hereby authorize and direct the nancial institution to return said funds to Equitable as soon as possible.

If the funds erroneously deposited to my account have been drawn from that account so that return of those funds by the

bank to Equitable is not possible, I authorize Equitable to recover those funds by off-setting the amount erroneously paid

to me from any future payments from Equitable until the amount of the erroneous deposit has been recovered, in full. It is

understood that I will be notied by Equitable when this condition occurs.