4. DISTRIBUTIONS
In general, you may not take a distribution of the vested portion of your contributions in the Plan until you have retired or otherwise
separated from service with the firm, or have become disabled, or died. Under certain circumstances, you may make withdrawals of your
contributions during your employment with the firm, as described below.
A.
You may withdraw any amount from your Rollover Contributions (and Post-Tax Contributions, if any) at any time.
B.
You may withdraw any amount from your 401(k) Elective Contributions and Safe Harbor Employer Contributions when you have
attained age 59½.
C.
You may withdraw any amount from the vested portion of your other employer contributions (including Matching Contributions,
if any) when you have attained age _______.
D.
If this box is checked, the Employer elects to enable you to make a withdrawal of your vested Nonelective Contributions
(and Matching Contributions, if any) if you have been a participant in the Plan for at least 5 years.
E.
If this box is checked, the Employer elects to enable you to make a withdrawal of your vested Matching Contributions and
Nonelective Contributions that have been in the Plan for at least 2 years.
F.
If this box is checked, the Employer elects to enable you to make hardship withdrawals.
If Box F, above, is checked and you incur an immediate and heavy financial need, which cannot be satisfied by other sources that are
reasonably available to you, you may be eligible to make a hardship withdrawal from your amounts in the Plan. An “immediate and heavy
financial need” includes (1) purchase of your principal residence; (2) preventing foreclosure on, or your eviction from, your principal
residence; (3) payment of tuition and related expenses for post-secondary education for you, your spouse or dependents; (4) payment of
certain medical expenses for you, your spouse or dependents; (5) payment of funeral or burial expenses for certain family members or
dependents; or (6) payment of certain expenses to repair damages to your principal residence. Some amounts, including Safe Harbor
Employer Contributions, cannot be distributed on account of hardship. See the SPD that is available from the Plan Administrator for more
information on hardship withdrawals.
5. CONTACT INFORMATION
A.
Employer: _________________________________________________________________________________________________________
Employer Address: _________________________________________________________________________________________________
City:_______________________________________________________
State:_________________
Zip Code: ___________________
Daytime Telephone Number: (
)
–
Email: _________________________________________________________
B.
Employer Plan Number: ___ ___ ___
C.
Employer Tax ID Number: ___ ___ – ___ ___ ___ ___ ___ ___ ___
D.
Plan Administrator (The Employer is the Plan Administrator. The individual(s) authorized to act as, or on behalf of the Plan Administrator is/are)
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
IF YOU HAVE ANY ADDITIONAL QUESTIONS, PLEASE CONTACT THE FIRM’S PLAN ADMINISTRATOR OR REFER TO THE SPD AVAILABLE
FROM THE FIRM’S PLAN ADMINISTRATOR.
Page 3 of 3