Request For Hardship Withdrawal (Page 2 of 3) in pdf

The amount of this withdrawal will be used to satisfy the following immediate and heavy financial need:

 To pay unreimbursed medical expenses that I will incur for myself, my spouse or my dependents; or

 To purchase any principal residence for myself (excluding mortgage payments); or

 For payment of tuition or room and board for the next 12 months of post-secondary education for myself, my spouse, my

children or my dependents; or

 To prevent eviction from my principal residence or the foreclosure of the mortgage on my principal residence; or

 To pay burial or funeral expenses for my deceased parent, spouse, children or dependents; or

 To pay expenses for the repair of damages to my principal residence that would qualify as tax deductible casualty

losses.

As proof that there exists an immediate and heavy financial need to draw upon the deferral portion of my account, I am

submitting the following required documents:

 Medical Expenses — an invoice from the health care provider and/or a copy of the Explanation of Benefits from the insurance

carrier setting forth the amount of the unreimbursed expenses.

 Principal Residence – a copy of the contract of sale and mortgage application signed by both parties.

 Tuition or Room and Board Expenses – a bill from the post-secondary school plus a summary of any financial aid I am eligible

to receive.

 Eviction/Foreclosure – an actual legal notice of eviction, notice of foreclosure, or other evidence showing the commencement of

legal action is required.

 Burial or Funeral Expenses – a copy of the death certificate and a bill detailing the cost of a funeral, burial or cremation.

 Repair of Damages to Principal Residence – an estimate or bill for repairs and proof that insurance proceeds did not cover the

amount of the expense claimed as a hardship.

INCOME TAX WITHHOLDING

Some or all of your distribution may be subject to Federal and state income tax withholding. If required by law, Federal income tax will

be withheld at a flat rate of 10%. If required by your state, Pentegra will withhold state income tax at the state’s prevailing withholding

rate.

 I do not want federal income tax withheld from the non-eligible rollover portion of my distribution.

I hereby certify that I have reviewed the “Special Tax Notice Regarding Plan Payments” within the period required by federal

tax law and that I hereby waive the 30 day waiting period as allowed by law. I further certify that the representations I have

made herein with respect to my Financial Hardship may be relied upon by the Plan in making this distribution. I acknowledge

a $50 distribution fee will be deducted from the proceeds of my withdrawal.

Signature of Member

Date

TO BE COMPLETED BY THE EMPLOYER

On behalf of the above named Employer, I certify that the member’s signature above is that of the participant making the request and I

agree that the employer contributions for this member will be suspended in accordance with the provisions of the Plan, if applicable.

Signature of Authorized Representative

Date

MEDC Form 106-M52 (Hardship Withdrawal)

Pentegra Retirement Services

108 Corporate Park Drive

White Plains NY 10604

Phone 1-866-633-4015

fax 914-694-6429

Request For Hardship Withdrawal Page 2