HARDSHIP WITHDRAWAL APPLICATION - CalSTRS.com

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PERSONAL INFORMATION (please print clearly using black or blue ink) NAME: ________________________________________ ___________________ SOCIAL SECURITY NUMBER: _______________________ ADDRESS: ________________________________________ __________________________________ APT: ________________________ CITY: ________________________________________ ______________________ STATE: ______ ZIP CODE: ________________________ DAY PHONE:__________________________________ _________________ EVENING PHONE: _____________________________________ EMAIL: ________________________________________ ________________________________________ _________________________ SCHOOL DISTRICT PLAN NUMBER: ________________________________________ _____________ _DATE OF BIRTH: _____ /_____ /______ (Not required) INSTRUCTIONSHARDSHIPWITHDRAWAL APPLICATIONPAGE 1 of 6 PLEASE NOTE: AN INCOMPLETE APPLICATION OR N

HARDSHIP WITHDRAWAL APPLICATION HARDSHIP WITHDRAWAL / PAGE 2 of 6 CHOOSE TAX WITHHOLDING AND GROSS UP ELECTION Tax Withholding Elections:Regardless of whether or not federal or state income tax is withheld, you are liable for taxes on the taxable portion of the payment.

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