Request For Hardship Withdrawal

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Pentegra Retirement Services
Pentegra Defined Contribution Plan for Financial Institutions (formerly known as Financial Institutions Thrift Plan)
REQUEST FOR HARDSHIP WITHDRAWAL
IMPORTANT NOTICE
:
Please carefully review the Special Tax Notice Regarding Pentegra Defined Contribution Plan for Financial Institutions
Payments, which you have previously received prior to completing this form. If you cannot locate this document, contact
your employer, log on to the Pentegra website at or contact Pentegra and a copy will be sent to you.
EMPLOYEE DATA
(Please Type or Print Clearly):
Name:
Last
First
Middle Initial
Current Address:
Street
City
State
Zip
Social Security Number:
E-mail:
Home Phone Number
Name of Employer:
Employer Number:
 Same as above  Other
Mail check to:
HARDSHIP WITHDRAWAL REQUEST
I hereby request a hardship withdrawal from my account as follows:
 The amount necessary to satisfy my approved Financial Hardship or, if less, the total amount available from my Pentegra
Defined Contribution Plan for Financial Institutions account; or
 $
(amount must be for less than the approved Hardship, but at least $1,000)
 I want my distribution “grossed up” by 10% to offset the 10% excise tax on premature distributions.
PLEASE SEND MY PAYMENT:
 Regular Mail
 ACH (Automated Clearing House electronic transfer - complete bank information below)
ABA# (if any)
Name of Plan, IRA, or Bank
Address of Plan, IRA, or Bank
Branch/Plan # (if any)
Account #:
Account Name:
IRS regulations consider a Financial Hardship to be a specific, immediate and heavy financial need. In order to receive any 401(k)
assets, you must first receive the entire available balance in your non-401(k) monies. This may result in a suspension of your employer
matching contributions, if applicable.
I certify that the specific amount of my Financial Hardship is $
and that I am not capable of satisfying this need,
as described below, by any of the following means. If no amount is entered, this request will automatically be denied.
 Reimbursement or compensation from insurance or any other source; or
 The sale of any of my assets; or
 Stopping my contributions (401(k) and/or after-tax) to the Plan (or any other qualified plan); or
 Getting a distribution or loan from the Plan or any other plan; or
 Getting a loan from a commercial lender.
(Continued on reverse side)
MEDC Form 106-M52 (Hardship Withdrawal)

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