Form Dc-1942-0313 Financial Hardship Request Instructions And Application printable pdf download

THE STATE OF MARYLAND 401(K) PLAN

FINANCIAL HARDSHIP REQUEST INSTRUCTIONS

THE ADMINISTRATION OF THE PLAN IS AUDITED FROM TIME TO TIME BY THE INTERNAL REVENUE SERV-

ICE FOR DETERMINATION OF FULL ADHERENCE BY ALL PARTIES TO THE REQUIREMENTS OF THE PLAN.

IF THE PLAN SHOULD NOT BE ADHERED TO, THE TAX BENEFITS OF THE PLAN CAN BE DENIED TO ALL

PARTICIPANTS IN THE PLAN. FOR THIS REASON, THE ADMINISTRATOR OR THE REVIEW COMMITTEE IN

YOUR CITY/COUNTY, IF THERE IS ONE, MUST ADHERE STRICTLY TO IRS REGULATIONS.

“Financial Hardship” shall be defined as: (i) an immediate and heavy financial need arising as a result of accident, ill-

ness or other emergency, in circumstances of sufficient severity that a Participant or his family is clearly endangered

by present or impending economic want or privation; or (ii) financial need arising as a result of the expenditure of

funds in order to purchase a home (excluding mortgage payments) or to provide for the post-secondary education of

the Participant or any member of his immediate family.

Payment may not be made to the extent that such hardship may be relieved:

a) Through reimbursement or compensation by insurance or otherwise,

b) by liquidation of the Participant’s assets, to the extent the liquidation of such assets would not itself cause

severe financial hardship, or

c) by cessation of deferrals under the Plan

NOT considered a “severe financial hardship” are forseeable personal expenses normally budgeted, such as:

1. Normal monthly bills

2. Payment of loans

IF YOU FEEL THAT YOU QUALIFY FOR A WITHDRAWAL OF FUNDS, PLEASE COMPLETE THE INFORMA-

TION REQUESTED ON THE ATTACHED SHEETS. INFORMATION MUST BE COMPLETE OR THIS FORM WILL

BE RETURNED FOR ADDITIONAL INFORMATION, THEREBY CREATING A DELAY IN CONSIDERATION. FOR

YOUR REQUEST TO BE CONSIDERED FOR APPROVAL, SUPPORTING DOCUMENTS MUST BE SUBMITTED

WITH THIS APPLICATION. THE FOLLOWING ARE EXAMPLES OF SUPPORTING DOCUMENTS THAT MIGHT

BE SUBMITTED.

1. Medical bills (amount not covered by insurance)

2. Insurance statement showing amounts paid and amounts not paid

3. Applicable death certificate

4. Doctor’s statement verifying disability

5. Applicable separation or divorce agreement

6. Police or Fire accident report

7. Other documentation as may be needed

8. A W-4 must be submitted with this form.

AFTER DECEMBER 31, 1988, ONLY THE PARTICPANT’S CONTRIBUTIONS MAY BE DISTRIBUTED IN THE

EVENT OF A FINANCIAL HARDSHIP; ANY EARNINGS MUST REMAIN WITH THE PLAN. THE PARTICIPANT

SHOULD BE AWARE THAT ALL AMOUNTS RECEIVED ARE SUBJECT TO ORDINARY INCOME TAX AND MAY

BE REQUIRED TO PAY AN ADDITIONAL 10% TAX TO THE IRS ON SUCH AMOUNTS RECEIVED. ALL TAX

FORMS WILL BE RECEIVED BY THE PARTICIPANT BY THE DEADLINE ESTABLISHED BY THE IRS FOR W-2

REPORTING.

You will be notified of whatever action has been taken regarding your claim. If you have any further questions con-

cerning this matter, please feel free to contact the Plan Administrator.

DC-1942-0313

Form Dc-1942-0313 Financial Hardship Request Instructions And Application