Request For Hardship Withdrawal Page 3
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3Pentegra Retirement Services
Pentegra Defined Contribution Plan for Financial Institutions (formerly known as Financial Institutions Thrift Plan)
SPOUSAL CONSENT FOR A WITHDRAWAL
EMPLOYEE DATA
(Please Type or Print Clearly)
Employee Name
(Last)
(First)
(Middle Initial)
Address
(Street)
(City)
(State)
(Zip)
Employee’s Social Security #
E-Mail
Home Phone
Employer Number
Employer Name
I, the undersigned, am the Employee’s spouse and agree to allow my spouse to take a withdrawal from his/her
Pentegra Defined Contribution Plan for Financial Institutions account which is subject to the Qualified Pre-
retirement Survivor Annuity and the Qualified Joint and Survivor Annuity rules. I understand that I have the right to
have the Pentegra Defined Contribution Plan for Financial Institutions pay my spouse’s applicable retirement
benefits in the Qualified Pre-retirement Survivor Annuity (“QPSA”) payment form if my spouse dies before he/she
begins receiving retirement benefits or in the Qualified Joint and Survivor Annuity (“QJSA”) payment form if I do
not consent to an alternative payment form upon my spouse’s retirement. I understand that by signing this
agreement, I may receive less money than I would have received under the QPSA or QJSA payment form
because of my consent to this withdrawal.
I understand that I do not have to sign this agreement. I am signing this agreement voluntarily.
Name of Spouse
Signature of Spouse
Date
State of:
___________________________________
ss.:
County of:
___________________________________
On this
of
, 20
personally appeared before me the said named
, to me known and known to me to be the person described in and who
executed the foregoing instrument, and he(she) acknowledged that he(she) executed the same.
(Seal)____________________________________(Notary
Public)
STAMP OR SEAL REQUIRED
My commission expires _______________________
TP Form\Spousal Waiver-Wdl. Form 114
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Pentegra Retirement Services
108 Corporate Park Drive
White Plains NY 10604
Phone 1-866-633-4015
fax 914-694-6429
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