Hardship Withdrawal - Notice And Election Form Page 2
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3HARDSHIP WITHDRAWAL - NOTICE AND ELECTION FORM
To be completed by the Participant and reviewed/approved by the Employer
Plan Name:
P
I
ARTICIPANT
NFORMATION
Participant’s Name:
Social Security No::
Marital Status:
Married
Single
Legally Separated
Birth Date:
Hire Date:
Address:
City:
State:
Zip:
Daytime Telephone Number:
Email Address:
R
H
(C
O
)
EASON FOR
ARDSHIP
HECK
NE
Unreimbursed medical expenses (as defined in IRC Section 213) incurred by me, my spouse or dependent(s)
Purchase of my principal residence
Payment of tuition or related educational expenses for the next 12 months for me, my spouse, or dependent(s)
Payment necessary to prevent eviction or foreclosure on my principal residence
Payment of Funeral Expenses for my parent, spouse, child or dependent
Payment of expenses for the repair of damage to my principal residence that would qualify for a casualty loss
deduction
W
A
(S
O
)
ITHDRAWAL
MOUNT
ELECT
NE
Gross Amount
Withdraw $___ ____ from my vested account balance. I understand that if I elect
any income tax withholding it will be deducted from this amount.
Net Amount
Withdraw $__________ from my vested account balance plus withdraw any
income tax withholding as elected below.
**Please note that certain Employer contributions such as Safe Harbor, Qualified Non-Elective, Qualified Matching,
ROTH and certain Prevailing Wage contributions cannot be used to fund a Hardship Withdrawal, and may affect the
amount available to you. If the amount available is less than requested, the maximum available will be distributed to
you. If you have any questions regarding the availability of funds in your retirement account, contact our Participant
Services Group at 916.773.3480 or email us at PSG@Polycomp.net.
I
T
W
O
NCOME
AX
ITHHOLDING
PTIONS
Any taxable amount distributed to me as a hardship withdrawal is taxable to me at my regular
income tax rate for the year in which received.
I may choose to have any Federal or California state income tax withholding rate applied to this
hardship withdrawal, which means that I may elect to have zero withholding. I have indicated
my withholding election below.
Unless otherwise indicated below, 10% of my distribution will be automatically withheld for
Federal income taxes and 1% will be automatically withheld for California state income taxes.
In addition, a 10% federal tax penalty for early withdrawal from a retirement plan will be applied
to your annual tax return, unless the hardship is due to medical expenses as defined in IRC
Section 213.
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