1 PLAN NAME:_____. Hardship Withdrawal Request AND Election . As a participant in the above Plan, I am requesting a Hardship Withdrawal of previous salary deferral contributions on account of an immediate and heavy financial need due to: Indicate applicable reason for Hardship Withdrawal Request by entering your initials by an option listed: ( ) Medical expenses incurred or necessary for the medical care of the participant, spouse or dependent of the participant. Current Medical Bills Only. ( ) Purchase of the participant's principal residence (excluding mortgage payments). We will require the Closing Settlement Statement document. ( ) Payment of tuition and related educational fees for the next 12 months of post-secondary education for the participant spouse or dependent of the participant. ( ) Payment of amounts necessary to prevent the eviction of the participant from the participant's principal resident or foreclosure on the mortgage of the participant's principal residence. ( ) Payment of funeral expenses for participant's spouse, parents, children, named beneficiary or dependent of the participant.
2 The documentation for the funeral expenses need to be in your name. ( ) Repair of damage to the participant's principal residence that would qualify for the casualty deduction under Code Section 165 (deductible for damage caused by natural disasters). Amount requested: $_____ or Maximum . Availability of a specific dollar amount requested is subject to fees or expenses, if applicable. The maximum Hardship distribution cannot exceed the cumulative employee deferral contribution total to-date, net of earnings; or, the liquidation value of employee deferral contribution benefits , if less. *PLEASE ATTACH COPIES OF THE APPLICABLE DOCUMENTATION OF THE REASON FOR THE. Hardship AND THE AMOUNT REQUESTED ABOVE. Optional: I elect to have ____% Federal taxes withheld from the gross Withdrawal total. UNLESS MANDATED BY LAW. Optional: I elect to have ____% State taxes withheld from the gross Withdrawal total. UNLESS MANDATED BY LAW. I understand and hereby agree that the employer may Request additional information that may be required to confirm my need.
3 This may include a financial statement, tax return, and such other financial information that the employer deems necessary to approve the Withdrawal . I further understand that a Hardship Withdrawal is a taxable distribution and it is subject to Early Withdrawal Penalties if I am under the age 59 years of age, and that I am not allowed to make employee salary deferral contributions to the Plan for a period of six months from the date of the Hardship Withdrawal . I also acknowledge that I have been advised as to the personal tax implications associated with the employer's acceptance of my Request and do hereby release my employer, the Plan Administrator, and the Trustees of the Plan from and against any and all claims the undersigned may have or hereafter claim to have against said Administrator, Trustees, and employer, but only with respect to my Hardship Withdrawal or any future consequences resulting from such. I further certify that: (1) The amount requested is not in excess of the immediate and heavy financial need (including amounts necessary to pay any federal, state, or local income taxes or penalties anticipated to result from the distribution.)
4 (2) I have no other reasonably available resources from which these funds may be obtained, either through the distribution or non-taxable loan from any other Plan of the Employer, or through a loan from commercial sources under reasonable commercial terms. (3) None of the money I am requesting to withdraw is subject to a Qualified Domestic Relations Order. (4) I have liquidated all reasonable assets, and I am not being reimbursed or compensated by insurance. (5) Stopping all elective contributions or other employee contributions under the Plan would not satisfy my Hardship . (6) I acknowledge and agree that a $ Distribution Fee will apply and will be deducted from my distribution. Hardship Withdrawal Request Form Page 2. In Witness Whereof, the undersigned has hereto set (his)(her) hand this _____ day of _____, 20_____. Signature of Participant: Witnessed By: _____ _____. Notary Print Participant Name: _____. Participant Social Security Number: _____. Participant Mailing Address: _____.
5 **. SPOUSAL CONSENT. (For Amounts over $5, ). Notary Required I hereby approve of, and consent to, my spouse's Election for a Hardship Withdrawal . I understand that this Election may have the effect of reducing the benefit I would receive under the Plan should my spouse die prior to retirement. In Witness Whereof, the undersigned has hereto set (his)(her) hand this _____ day of _____, 20_____. Signature of Spouse: Witnessed By: _____ _____. Notary Print Name of Spouse: _____. **. EMPLOYER ACCEPTANCE: I hereby: authorize do not authorize, this Hardship distribution to the above name Participant. I further certify that this decision has been rendered in a consistent and und uniform manner to all like Request . _____ _____. Authorized Plan Representative Date Section 3 Spouse's Signatures Legal Requirement: This is an important decision. Before signing, be sure you understand what retirement benefits you'll receive and what benefits you'll no longer be eligible to receive. I, _____, (name of the spouse of the plan participant), am the spouse of _____ (name of plan participant).
6 I understand I have the right to have benefits paid in the form of a QJSA benefit (see Sections 8 and 9 for explanation and examples). I. agree to give up this right. I understand by signing this agreement, I may receive less money than I would have received under the QJSA form of payment and I will receive a reduced amount when my spouse dies, depending on the payment form and beneficiary my spouse chooses. I agree the benefits paid under this plan will be paid as selected on this form. However, my spouse can change the payment form unless I. restrict my spouse's ability to change by marking the box below. I understand my spouse can change to the QJSA form of benefit payment without my consent. I understand I don't have to sign this agreement. I'm signing this agreement voluntarily. If I don't sign, the plan may require that my spouse and I receive payments from the plan in the QJSA form of benefit Withdrawal (see Sections 8 and 9). Federal tax law requires a payment cannot be made sooner than 30 days, nor later than 180 days after my spouse receives this Early Withdrawal of Benefit Form.
7 However, my signature below will serve as consent to the plan participant's decision relating to the waiver of the 30-day waiting period to 7**days. Mark this box if applicable: My consent is required for any change to the benefit chosen on this Election form. My consent is only for Spouse's Signature Type or Print Name Date Mark this box if the form of benefit chosen applicable: on this Election form. X / /. Plan Representative Signature: The spouse Plan Representative Type or Print Name Date appeared before me and signed this consent. Signature: X / /. Notary Public: The person signing as spouse appeared before me and signed Notary Signature the above consent. Sworn to and subscribed before me this _____ day of _____, X _____. 20_____, in the State of _____, County of _____. Notary expires on: _____/_____/_____. Type or print name of Notary The person who signed as spouse is personally known to me, or Type of Identification: The person who signed as spouse produced identification. If your state has specific notary acknowledgment requirements then the notary will need to include any additional acknowledgment and attach it to this Withdrawal form.
8 If spouse cannot Plan Representative It Plan Representative Signature Date be located: has been established to my satisfaction the X / /. spouse cannot be located. * The information and signatures in these sections are required by the Internal Revenue Code 417,402(f), 411(a)(11). ** Some plans may not allow the 30 days to be waived in favor of 7 days. Hardship Withdrawal Request and Election 08/20/2013.