Hardship Withdrawal Request
][Form 11][ FDSTHD][01/09/04 ][Page 1 of 3 [401K Plan]][000:121203
][JAC1/87905117
Participant Information
Last Name First Name MI Social Security Number
Address - Number & Street E-mail Address
Mo Day Year
City State Zip ❑ Married ❑ Unmarried
Date of Birth
( )
Daytime Phone Are you a U.S. citizen or resident alien? ❑ Yes ❑ No
Account Extension
An account extension identifies funds that were transferred to a spousal beneficiary or alternate payee due to
divorce or death. If you have an account extension, enter it here . For assistance, please
contact the Service Center at: 1-xxx-xxx-xxxx.
Type of Hardship – Choose one
❏ MEDICAL CARE - as defined in the Internal Revenue Code of 1986, as amended, on behalf of myself, my
spouse, or my dependents for whom I can claim an exemption on my federal tax return.
❏ PRINCIPAL RESIDENCE - costs directly related to the purchase of my principal residence (not including
mortgage payments).
❏ EVICTION AND/OR FORECLOSURE - Need to prevent eviction from principal residence and/or foreclosure
on the mortgage of my principal residence (depending on Plan provisions).
❏ TUITION - Payment of tuition for the next twelve months of post secondary school education for myself, my
spouse, my children, or dependents.
Hardship Amount
$ ❏ Gross Amount ❏ Net Amount
Distribution Delivery
❏ Send by Express Mail and deduct $25.00 from my check for express charges. Note: A street address must
be provided. This option is only available for checks payable to you.
❏ Send to the following Alternate Mailing Address - Complete this section only if you want a distribution
check mailed to a residential address OTHER than the one listed in the Participant Information section. You
may not designate a bank or financial institution in this section.
Address City State Zip
Federal and State Income Tax Withholding
Federal Income Tax - Federal income tax will be withheld at the rate of 10%, unless Service Center is directed
otherwise below.
If you would like additional federal income tax withheld, indicate amount. $ or %
❏ Do NOT withhold federal income tax from my hardship distribution.
State Income Tax - If you live in a state that mandates state income tax withholding, it will be withheld.
❏ Check here if you live in a state that does not mandate state income tax withholding and would like state
income tax withheld.
If you would like additional state income tax withheld, indicate amount. $ or %
Hardship Withdrawal Request
Last Name First Name MI Social Security Number
][Form 11][ FDSTHD][01/09/04 ][Page 2 of 3 [401K Plan]][000:121203
][JAC1/87905117
Spousal Consent
I hereby consent to the participant’s election to commence distributions under a payment option other than a
qualified joint and survivor annuity. I understand that by providing such consent, I am waiving my right to receive
a survivor annuity which would be payable to me upon the participant’s death. I understand the effect of this
consent.
SEAL
Spouse’s Signature Date Notary Public’s Signature Date
Your Consent and Signature
Any person who knowingly presents a false or fraudulent claim is subject to criminal and civil
penalties.
My signature acknowledges that I have received, read, understand and agree to all pages of this form, and
affirm that all information that I have provided is true and correct.
Participant return to:
Participant Signature Date Plan Administrator
Your Employer’s Authorization
❏ I certify that the recordkeeping system has the accurate termination date
and vesting percentage, if applicable, and participant address. Please
process the request using this information.
OR
❏ I certify that the participant’s accurate vested percentage is %.
Please use this when processing the distribution.
The Plan Administrator certifies that all distribution information provided is
accurate. This request is in compliance with Plan provisions and applicable
federal law.
Plan Administrator return to:
PO Box 173764
Denver, CO 80217-3764
Phone: 1-xxx-xxx-xxxx
Fax: 1-303-737-4355
Authorized Plan Administrator Signature Date
][Form 11][ FDSTHD][01/09/04 ][Page 3 of 3 [401K Plan]][000:121203
][JAC1/87905117
Hardship Withdrawal Certification
The Internal Revenue Code (the "Code") imposes restrictions on the availability of before-tax monies from
§401(k) plans until the occurrence of one of the following: attainment of age 59 1/2; or severance of employment
(due to total disability, retirement or otherwise); or financial hardship as determined under present or future IRS
regulations (if allowed by the Plan); or death of participant; or any other reason specifically allowed under the
provisions of the Plan in which you are a participant.
Pursuant to the Code, the amount distributable upon hardship is limited. The distributable amount is limited to
the employee’s total elective deferrals as of the date of distribution, reduced by any previous hardship
distributions. Further, if the Plan allows, the distributable amount may be increased by 1) employer contributions;
and 2) the earnings allocable to the elective deferrals that were credited to your account no later than
December 31, 1988 or the end of the last Plan year ending before July 1, 1989, whichever is later.
The amount you request for hardship may not exceed the amount of your financial need. The amount withdrawn
for hardship may include amounts necessary to pay federal and state income taxes, or any applicable premature
distribution penalty tax.
Income Tax Withholding Applicable to Payments Delivered Outside the U.S.
If you are a U.S. citizen or a resident alien and your payment is to be delivered outside the U.S. or its
possessions, you may not elect out of federal income tax withholding.
If you are a non-resident alien, you must attach IRS Form W-8BEN. In general, the withholding rate applicable
to your payment is 30% unless a reduced rate applies because your country of citizenship has entered into a tax
treaty with the U.S. and the treaty provides for a reduced withholding rate or an exemption from withholding. To
obtain the IRS Form W-8BEN, call 1-800-TAX-FORM.
Contact your tax professional for more information.
Safe Harbor - Your Plan may allow for a hardship distribution based on a Safe Harbor test.
A distribution is deemed to be for an immediate and heavy financial need if it is made for any one or a
combination of the reasons specified in the Type of Hardship section of Page 1 of this form. In addition to the
rules enumerated above, a Safe Harbor hardship distribution is subject to the following additional rules:
The participant may have been required to receive all distributions (other than hardship distributions), and all
available nontaxable loans, from this and all other plans maintained by the employer (including a related
employer); and
The participant may not make any elective deferrals or after-tax contributions to the Plan for at least 6 months
(or longer if required by your Plan) after the hardship distribution to all plans maintained by the employer.
