Hardship Withdrawal Application Form (Page 4 of 5) in pdf

Motorola Solutions 401(k) Plan

HARDSHIP WITHDRAWAL APPLICATION

REASON

REQUIRED DOCUMENTATION AND INFORMATION

UNACCEPTABLE REASONS/

THAT MUST BE REFLECTED ON DOCUMENTATION

DOCUMENTATION

If you selected an immediate and heavy financial need for your dependent:

A dependent is anyone who meets the definition of a Qualifying Child or Qualifying Relative as described in Section 152 of the Internal Revenue Code,

determined without regard to subsections (b)(1), (b)(2), and (d)(1)(B) thereof.

By checking this box, I hereby certify that the person(s) I am requesting funding for would be considered as a dependent

as stated above. If this box is

not checked, I understand my hardship request will be rejected.

AUTHORIZATION

By signing below, I certify that:

1. I have read and understand the information contained within this form.

2. The facts presented in this request and in the documents used to substantiate my hardship withdrawal amount are true to the best of my knowledge and describe an

outstanding immediate and heavy financial need.

3. I have exhausted all other means available and meet the Plan requirements as stated in the Hardship Requirements section.

4. I hereby authorize Motorola Solutions 401(k) Plan and Voya to contact any person or business to confirm any facts or statements contained in this application and the

attached documents.

5. I certify, under penalties of perjury, that to the best of my knowledge and belief the information provided on this form, including the Social Security Number or Taxpayer

Identification Number, is accurate and complete and the attached documents are valid and complete and have not been altered or manipulated in any manner.

By signing below, I understand that:

If any required information or documentation is missing from my application, there will be a delay in receiving my withdrawal check or my application will be returned to me.

_____________________________________________________________

________________

PARTICIPANT’S SIGNATURE

DATE

PLEASE CONTINUE THROUGH TO AUTHORIZATION PAGE. ALL PAGES MUST BE RETURNED FOR PROCESSING.

HARDSHIP WITHDRAWAL / PAGE 4 of 5