Hardship Withdrawal Application Form Page 5
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5Motorola Solutions 401(k) Plan
HARDSHIP WITHDRAWAL APPLICATION
CHECKLIST
If your application is complete, please
PLEASE REVIEW YOUR APPLICATION CAREFULLY.
mail or fax the application and any
q
Verified that the Plan has your current address
required documentation to:
q
VIA FAX
Reviewed and completed the Hardship Requirements to determine
ELIGIBLE
if you are
to take a hardship withdrawal
(ONLY IF SPOUSAL CONSENT IS NOT
REQUIRED)
q
Indicated your
TYPE, AMOUNT, TAX WITHHOLDING
and
GROSS UP ELECTIONS
Voya Financial
q
Selected
DELIVERY METHOD
and removed ACH information on file
Attn: Motorola Solutions 401(k) Plan
if requesting a check
1-844-265-5839
q
VALID REASON
Selected a
for the withdrawal
VIA MAIL
Voya Financial
q
Confirmed that you have first exhausted all distributions (other than hardship
Attn: Motorola Solutions 401(k) Plan
withdrawals) and loans from all plans maintained by the employer
P.O. Box 24747
q
Provided the
REQUIRED DOCUMENTATION
Jacksonville, FL 32241-4747
q
Provided authorized
SIGNATURE
VIA OVERNIGHT DELIVERY
Voya Financial
If you have any questions or need to obtain additional plan or account information, please go online
Attn: Motorola Solutions 401(k) Plan
at or call the Motorola Solutions Service Center at 1-855-674-4015 (MSI401k)
(International number 904-791-2409) (TTY/TTD users call 1-800-579-5708). Customer Service
8900 Prominence Parkway
Associates are available Monday through Friday, 7:00 A.M. to 7:00 P.M. Central Time (excluding stock
Jacksonville, FL 32256-8264
market holidays).
HARDSHIP WITHDRAWAL / PAGE 5 OF 5
2B627052HARDSHY
12/21/2016
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