401(K) Hardship Withdrawal Form printable pdf download

401(k) Hardship

Withdrawal Request

Please be advised that you must submit the documentation outlined on the second page of this form.

A hardship is an immediate and heavy financial need for one of the six reasons listed in Section III.

Section I – Employee Information

Name: __________________________________________________________________ SS# or Employee # : ______________

Last

First

Middle Initial

Address: _______________________________________________________ City: _______________ State: _____ Zip: _______

Phone: __________________________________________________

E-mail: ________________________________________

Keep your address current with your employer and the Vista 401(k) plan.

Section II – Withholding Information

The plan will automatically withhold 10% of your distribution. You may also be subject to an additional 10% penalty. If you

would like to request we withhold additional federal tax, please indicate the additional amount you would like withheld.

Additional Federal Withholding Election: ______%

Section III – Hardship Information

Hardship Reason (check one): Please see the second page of this form for definitions and instructions on necessary

documentation.

� Unreimbursed Medical Care Expenses

� Burial or Funeral Expenses

� Purchase of Principal Residence

� Prevention of Eviction or Foreclosure

� Post-Secondary Educational Expenses

� Repair to Principal Residence Due to Casualty

Amount Requested: $___________

My financial need can not be satisfied through any of the following:

Reimbursement or compensation by insurance or otherwise;

2. Liquidation of the participant’s assets;

3. Ceasing contributions under the plan;

4. Other distributions of non-taxable loan from plans maintained by the employer or any other employer;

5. Borrowing from commercial sources on reasonable commercial terms.

Section IV – Hardship Payment Options

Upon receipt of completed paperwork, you will receive your hardship disbursement within ten (10) business days or less. There is a

distribution fee charged by the Trust Bank.

� I would like to receive a check ($20 fee)

� I would like to have payment direct deposited ($20 fee)

Complete the banking instructions below as directed by your banking institution. Please print clearly and include all

number(s) including any zeros.

Bank Name: ____________________________________________ Account Type: ____________________________________

A.B.A. Routing #: _________________________________________ Account #: ______________________________________

(IRS regulations require contributions to your 401(k) to be suspended for 6 months following an approved hardship. Contributions will

not automatically resume once stopped.)

Section V – Signature

I hereby certify the above information and elections made are accurate. I understand that the program, as described in the

official plan documents, will govern in all cases. I herby certify that I have read, understand, and agree to the terms and

conditions listed on this form.

Signature: ______________________________________________________ Date: ________________

401(K) Hardship Withdrawal Form

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