401(k) Hardship Distribution Request

Your Name *

First Name

Last Name

Please select an option below that best matches your immediate and heavy financial needs... *

Expenses incurred or necessary for medical care, described in U.S. Code section 213(d), for you or your spouse, children, or dependents.

The purchase (excluding mortgage payments) of a principal residence for the Participant.

Payment of tuition and related educational fees for the next 12 months of post-secondary education for you or your spouse, children or dependents.

The need to prevent the eviction of you from your principal residence (or a foreclosure on the mortgage on your principal residence).

Payments for burial or funeral expenses for your deceased parent, spouse, children or dependents.

Expenses for the repair of damage to your principal residence that would qualify for the casualty deduction.

Expenses incurred on account of a federally declared disaster.

Do you have an active loan on your 401(k) account? *

Yes

No

Prior to preparing this request, have you explored and attempted to collect necessary funds though all other reasonable means? *

Have an active loan against your 401(k) and have requested funds from other legitimate sources that are available to you (banks, financial aid, family, etc.).

Yes

No

Do you expect to require additional hardship distributions within the next six (6) months? *

Yes

No