Hardship Withdrawal - Notice And Election Form
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1
2
3Participant:
Plan:
Date:
You are receiving this package because you indicated an immediate financial need and have exhausted all other means by which to
meet that need. For us to proceed with the distribution, we need you and your employer to complete the following form and return to
Polycomp. Keep a copy of signed and returned paperwork for your own files.
RETURN TO
DESCRIPTION
ACTION REQUESTED
POLYCOMP BY
Complete as follows:
Make sure your personal information is accurate, and your address is
complete, including zip code and phone number.
Select the reason for taking the Hardship Withdrawal and elect how you
Hardship Withdrawal
would like to receive the distribution.
Two Weeks Before Funds
Notice and Election Form
are Needed
Indicate your election for Federal and State tax withholding from this
distribution as well as if you wish to waive the 30- day wait period.
Sign and date the form where indicated.
Have your employer sign and date where indicated.
Read carefully prior to completing Notice of Distribution.
We also
Retain for Your Records
recommend that you contact your personal tax advisor regarding the tax
Special Tax Notice
consequences associated with plan payments you receive.
RETURN COMPLETED FORM TO:
Polycomp Administrative Services, Inc.
3000 Lava Ridge Court, Suite 130
Roseville, CA 95661
Fax: 916.773.3484
Email: psg@polycomp.net
Polycomp Administrative Services, Inc. is a service provider. We do not process checks or hold trust assets.
If after 2 weeks from submitting your form to us you have not received your check, please contact your employer.
If you have any questions on how to complete this form, please call us at 916.773.3480 or 800.952.8800.
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