401(K) Hardship Withdrawal Form (Page 2 of 2) in pdf

401(k) Hardship

Withdrawal Request

Continued from Page 1

Hardship Documentation Requirements

Please take care to insure all documents are attached when you file your hardship or it cannot be processed

The amount you request cannot exceed your immediate and heavy financial need. Eligible amounts to be withdrawn are

limited to rollover account balances, employee pre-tax contributions plus interest through December 31, 1988 and employee

pre-tax contributions only after January 1, 1989. (The amount of money you receive may be less than the amount of money

requested because we will withhold 10% from the taxable portion of your withdrawal that is paid directly to you.) In addition,

you may be required to pay a 10% tax penalty on the taxable portion of your withdrawal.

Unreimbursed Medical Care Expenses

– Expenses for medical care previously incurred by the participant, spouse, or

dependents and not previously reimbursed through any other means.

• Copies of bills and Explanation of Benefits (EOB) from the insurance carrier.

• Copies of estimated charges and predetermination of benefits from insurance carrier.

• Proof of insurer denial of coverage.

• Proof of dependency if applicable.

Post-Secondary Educational Expenses

– Tuition, educational fees, and/or room and board expenses for next 12 months of

post-secondary education for participant, spouse, or dependents.

• Student’s name and relationship to participant.

• Bill from educational institution or letter verifying estimated cost.

• Proof of enrollment.

• Proof of accreditation.

Burial or Funeral Expenses

– Payment necessary to fund burial or funeral expenses for parent, spouse, dependents.

• Copy of death certificate and bill from funeral home showing costs of burial and funeral.

• Proof of relationship to the person claiming hardship for.

Purchase of Principal Residence

– Costs directly related to purchase principal residence (excluding mortgage payments).

• Copy of signed purchase agreement.

• Copy of legal expenses incurred.

• Copies of bills showing additional fees incurred in purchase of home.

• Document from mortgage lender indicating that current home purchase is primary residence.

Prevention of Eviction/Foreclosure

– Payments necessary to prevent eviction from primary residence or foreclosure on

mortgage of primary residence.

• Formal legal document giving notice, as required by state law, that if the stated overdue rent or mortgage payment is not

received, by a specified deadline, formal eviction or foreclosure will be instituted.

• Proof of residence.

Repair to Principal Residence Due to Casualty

– Payments necessary for repairs due to natural disasters.

• Evidence of casualty, repair bill, and proof that insurance or other relief proceeds did not cover the casualty expenses

claimed as a hardship.

• Proof of residence.

• Proof that the Federal Government has determined the area of residence to be warranted assistance under Section 165.

• Proof of claim presented to Federal Emergency Management Association.

Vista/HardWith/0716

Vista 401(k) • P .O. Box 1878, Tallahassee, FL 32302-1878 • 1-866-325-1278 • FAX 850-425-8345 •

401(K) Hardship Withdrawal Form Page 2

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