401(K) Plan Financial Hardship Withdrawal Request (Page 2 of 4) in pdf

401(k) Plan Financial

Hardship Withdrawal Request

1-800-748-6128

Pension Plus Retirement Plans

FORM MUST BE COMPLETED IN ITS ENTIRETY WITH ALL REQUESTED DOCUMENTATION BEFORE IT WILL BE CONSIDERED.

PLEASE PRINT OR TYPE.

Name

Social Security Number

Address

Daytime Phone

City

State

Zip

In accordance with the provisions of IRS Reg. Section 1.401(k)1(d)(2)(iv)(A) and provisions of the Plan, and based on my answers to the

following questions, I hereby request withdrawal from my account as follows:

Withdrawal in the amount of: $____________________

Federal Tax Withholding — you may select zero:

$ ___________

or % _________

Payments to non-resident aliens are subject to a 30% federal withholding tax, and U.S. persons having their payment delivered outside

the United States may be subject to a 30% federal withholding tax, unless they are eligible for a reduced rate or exemption under a tax

treaty and the required IRS tax forms are submitted.

I would like to have my withdrawal mailed to me using expedited delivery for a fee of $50.00 that will be charged to my account.

[

]

[

]

I understand there is a onetime fee of $50.00 for this transaction that will be charged to my account.

The participant/beneficiary/alternate payee certifies, under penalty of perjury that to the best of his/her knowledge and belief the

information provided on this form, including the Social Security Number or Taxpayer Identification Number, is accurate and complete.

SIGNATURE

DATE

TIME STAMP

ONLY FOR STATE OF MICHIGAN HARDSHIP WITHDRAWAL COMMITTEE USE

EXPLANATION AND INSTRUCTIONS IF REQUEST FOR HARDSHIP DENIED:

Reason Circumstances Do Not Qualify:

Specific Additional Documentation Required:

HARDSHIP WITHDRAWAL COMMITTEE SIGNATURE

DATE

PLEASE RESUBMIT FORMS ALONG WITH ADDITIONAL REQUESTED DOCUMENTATION TO VOYA

FOR FINAL APPROVAL.

EXPLANATION AND INSTRUCTIONS IF REQUEST FOR HARDSHIP DENIED:

IF FINAL REQUEST IS DENIED, YOU MAY RESUBMIT ALL FORMS AND DOCUMENTATION FOR REDETERMINATION TO:

DTMB, Office of Retirement Services, 401(K) Plan, P.O. Box 30171 Lansing, MI 48909-7671

02/2017

MI640004HARDSHN

PAGE 2

401(K) Plan Financial Hardship Withdrawal Request Page 2

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