Hardship Withdrawal - Notice And Election Form (Page 3 of 3) in pdf

Federal Income Tax Withholding (check one box:

I do not want to have Federal income tax withheld from my hardship withdrawal.

I want to have

% Federal income tax withheld from my hardship withdrawal.

State income tax withholding (not applicable to non-California residents)(check one box):

I do not want to have State of California income tax withheld from my hardship withdrawal.*

I want to have

% State of California income tax withheld from my hardship withdrawal.

*Polycomp will accommodate your withholding requests to the extent allowed by the investment company holding the funds.

AYMENT

NSTRUCTIONS

Check

Direct Deposit- (if available)

Checking

Savings

Bank Name

City

State

Bank ABA/Routing Number (9 digits)

Account Number

Name as it appears on the account

AYMENT

NFORMATION

By signing below I am stating the following:

The amount of the withdrawal does not exceed the amount necessary to relieve the immediate and heavy financial



need as stated above.

I have obtained all distributions (other than hardship distributions) and all nontaxable loans from all plans maintained



by my employer.

I elect to receive payment immediately, thereby waiving my right to a period of at least 30 days to consider this



hardship.

I understand that fees pertaining to this Hardship Withdrawal may be deducted from my account and that I can contact



Polycomp for more details on these fees.



I understand I will not be able to make salary deferrals to the plan and all other plans maintained by my employer

for at least 6 months after I receive my hardship distribution, including all qualified and nonqualified plans.

IGNATURE

Plan Participant’s Signature

Date

I have reviewed the request made by the Participant and approve a hardship withdrawal based on the statements and documentation provided

by the Participant. I understand it is my responsibility to keep a copy of any documentation provided for the Plan’s records:

Plan Administrator (Employer):

Date:

Plan Administrator (Employer) Print Name:

If you have any questions on how to complete this form, please call us at 916.773.3480 or 800.952.8800. Completed form should be

returned to: Polycomp Administrative Services, Inc., 3000 Lava Ridge Court, Suite 130, Roseville, CA 95661

Page 2 of 2

Hardship Withdrawal - Notice And Election Form Page 3

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