Hardship Withdrawal Application Form (Page 3 of 5) in pdf

Motorola Solutions 401(k) Plan

HARDSHIP WITHDRAWAL APPLICATION

HOW WOULD YOU LIKE TO RECEIVE YOUR WITHDRAWAL?

Automated Clearing House:

You must

Expedited delivery.

I understand I will pay a nonrefundable

First class mail at no additional charge.

If you

already have banking information on file

fee of $50 which will be deducted from my account. If you

previously set up an ACH Direct Deposit election and

with the Plan for at least 7 days in order for

previously set up an ACH Direct Deposit election and you

you choose this option, in advance of submitting this

this payment to be deposited to your bank

choose this option,in advance of submitting this hardship you

hardship, you must delete your banking information

via ACH.

must delete your banking information from your file either

from your file either online or with a Customer

online or with a Customer Service Associate. If you do not

Service Associate. If you do not delete the banking

delete the banking information, your hardship request will be

information, your hardship request will be directly

directly deposited based on the banking instructions you have

deposited based on the banking instructions you

on file. You will not receive a check.

have on file. You will not receive a check.

REASON FOR HARDSHIP WITHDRAWAL AND CHECKLIST

Attach copies of any documents that will substantiate both the nature and the amount of the immediate and heavy financial need.

These copies will not be returned; therefore, you should not send originals.

The following circumstances are considered for immediate and heavy financial need under the Plan. If you have any questions about the qualifying reasons for a hardship

withdrawal or the acceptable forms of documentation, please contact a Customer Service Associate before proceeding. The contact information is available on the last

page of this form.

PLEASE CHOOSE ALL APPLICABLE TO YOUR CIRCUMSTANCE:

REASON

REQUIRED DOCUMENTATION AND INFORMATION

UNACCEPTABLE REASONS/

THAT MUST BE REFLECTED ON DOCUMENTATION

DOCUMENTATION

Explanation of Benefits (EOB),

and

•

Medical bills that do not

Unreimbursedmedicalexpenses

Must:

be dated within the past 12 months,

and

show portion paid by insurance

for medical care previously

reflect the amount paid by the insurance company,

and

•

Collection agency notices

incurred or anticipated by:

reflect the amount owed by the insured

•

Bills already paid

You

Corresponding bill from the provider

Your spouse

Must:

be dated within the past 12 months,

and

Your dependent

indicate the amount still owed by the insured

If applicable, I certify that I do not have insurance

•

Itemized tuition bill, and/or Room and Board statement provided by the

Estimate for tuition with no

Tuition, related educational

the school,

student name (general estimate

fees, room and board for

Must:

be dated within 4 months of the beginning of the quarter

from school). You need to

the next 12 months post-

or semester,

and

provide an actual tuition bill.

secondary education for:

contain student’s name,

and

•

Student loans

You

be due in the next 12 months

•

Financial aid award letters

Your spouse

Related Educational Fees

•

Bills already paid (except for

Your child

Text books bill or receipt dated within the last 4 months,

text books)

Your dependent

Off campus lease agreement signed and within the same time

period as the tuition bill,

Miscellaneous - provide supporting documentation

If borrowing, loan estimate from lender,

and

•

Rental/lease agreement for

Purchase of your principal

and

Signed purchase contract or intent-to-purchase agreement,

purchase of a primary residence

residence or costs directly

All above must:

•

Mortgage applications

related to your purchase

be dated within last 60 days,

and

•

Truth in lending disclosures

(excluding mortgage payments)

and

•

reflect the address of the residence being purchased,

Bills already paid

reflect the purchase price,

and

•

Land purchases only

reflect the amount of the down payment,

and

reflect a closing date no more than 6 months in the future,

and

reflect signatures of both buyer and seller

If building, you must also provide a copy of the signed builder's permit

or builder’s contract

If purchasing a mobile home, you must also provide a copy of the Deed

to show that you own the land

HARDSHIP WITHDRAWAL / PAGE 3 of 5

Hardship Withdrawal Application Form Page 3

Related Articles

Related forms

Related Categories