Hardship Withdrawal Request

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Company/Employer NameDivision A. Employer InformationE-mail AddressStateCitySocial Security Name/MIDate of Birth(mm/dd/yyyy)Last NameMailing AddressZip CodePhone B. Participant InformationOther ________________________________________ ____________________Purchase of my principal residence (excluding mortgage payments)( , provide contract signed by buyer and seller)Post-secondary educational expenses - up to the next 12 months( , provide qualifying tuition bill for self, spouse, children or dependents)Medical care pre-certification( , provide letter of pre-certification from insurance carrier for self, spouse, dependents or non-custodial child)

Hardship Withdrawal Request To request a hardship withdrawal, complete all applicable sections of this form, obtain any required signatures, and return the form to Diversified atthe above address.

  Request, Withdrawal, Hardship, Hardship withdrawal request, Hardship withdrawal