Hardship Withdrawal Application Form (Page 2 of 5) in pdf

Motorola Solutions 401(k) Plan

HARDSHIP WITHDRAWAL APPLICATION

CHOOSE AMOUNT TYPE AND AMOUNT REQUESTED

Amount Type: Depending on your account type, you may have the option to elect payment from the designated Roth account(s). (choose one):

I do not elect to receive a hardship withdrawal from my designated Roth account(s).

I elect to receive a hardship withdrawal from my designated Roth account(s). I understand that my withdrawal request will be satisfied by first

liquidating my non-Roth account(s) and then my Roth account(s).

I elect to receive a hardship withdrawal from my designated Roth account(s). I understand that my withdrawal request will be satisfied by first

liquidating my designated Roth account(s) and then my non-Roth account(s).

Note:

If you do not elect an option above, we will not withdraw from the designated Roth account. If you elect to withdraw from your designated Roth account(s)

and do not have one, we will withdraw from the non-Roth account(s).

Amount Requested: Withdraw the following (choose one):

Maximum available

$_____________

(not to exceed amount documented)

(indicate the total dollar amount)

Note:

If your available hardship withdrawal amount based on your current account balance is less than the financial need specified above, the hardship

will be processed up to the maximum amount available. If you elected an additional tax withholding, we will process using the default withholding rate

of 10% for federal taxes and the required state tax, if applicable.

If your hardship withdrawal amount is approved for a partial amount, based on the supporting documentation provided, the hardship will be processed up

to the partial amount approved. If you elected an additional tax withholding and did not elect to gross up, we will process using the default withholding rate

of 10% for federal taxes and the required state tax, if applicable.

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. If you

do not have a sufficient amount withheld, you may be subject to tax penalties under the Estimated Tax Payment rules. An election made for a single non-recurring

distribution applies only to the payment for which it is being made. You are responsible for understanding and planning for the tax implications of any withdrawal.

You may wish to contact your financial/tax advisor before submitting this form.

Federal Withholding Rules: Non-periodic payments — 10% withholding

Non-periodic, non-rollover eligible payments from pensions, annuities, and IRA’s are subject

to a flat 10% federal withholding rate unless you choose not to have federal income tax withheld. These include for example, required minimum distributions and

hardship withdrawals. You can choose not to have withholding applied to your non-periodic distribution by checking the applicable box below. You may also elect

withholding in excess of the flat 10% rate.

Federal Withholding Elections:

DO NOT

withhold any federal income tax unless mandated by law.

withhold federal taxes using the default withholding rate of

10%.

Additional amount

you want withheld from your payment

$_______________ (Note:

This amount is in addition to the default withholding rate of 10%.)

Note:

If no federal withholding election is checked above, we will withhold using the default withholding rate of 10%.

Notice:

Payments to non-resident aliens are subject to a 30% federal withholding tax, and U.S. persons with a residential mailing address outside the United

States may be subject to a 30% federal withholding tax, unless they are eligible for a reduced rate or exemption under a tax treaty and the required IRS tax

forms are submitted.

State Withholding Elections:

DO NOT

withhold any state income tax unless mandated by law.

withhold state taxes in the amount of

$________ or ________%

(If you make this election, a dollar amount or percentage must be specified

and cannot be less than any required withholding.)

Note:

If no state withholding election is checked above or if your state requires a greater amount of withholding, we will withhold at the rate specified by

your state of residence for the type of payment you are receiving. In some cases, your state specific withholding election form is required to opt out of

withholding or to choose a rate other than the state’s default rate. Refer to your plan’s website and/or your State Department of Taxation for details.

Gross Up Elections:

You may elect to increase the amount of your withdrawal so that the check you receive will be for the amount you requested after your elected

tax withholding and anticipated penalties are withheld. This is called gross up. If there are no changes to the tax withholding elections above, and you elect to

gross up, your withdrawal amount will be increased to cover the default withholding rate of 10% for federal taxes and the required state tax, if applicable. Please

choose from each gross up options below:

For example: If your stated withdrawal need was $1,000, you elected to gross up and have 10% + $100 withheld for federal taxes, the $1,000 pre-tax withdrawal amount could be

increased to $1,222.22. You would receive a net check amount of $1,000; the additional $222.22 (10% + $100 of $1,222.22) would be sent to the IRS to pay taxes. You may only

increase the withdrawal amount if there are sufficient funds available in your account.

Gross up for state:

Yes

Gross up for federal:

Yes

Gross up for penalty:

Yes

Note:

If no gross up election is checked above, we will not gross up your withdrawal.

HARDSHIP WITHDRAWAL / PAGE 2 of 5