Financial Hardship Distribution Form printable pdf download

I.B.E.W. Local No. 8 401(k) Plan

1-877-864-6644

FINANCIAL HARDSHIP DISTRIBUTION FORM

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Use this form to request a payment of benefits on account of financial hardship while you are still employed.

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Use this form only after you have requested all other available distributions.

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Your choices on this form may affect your taxes. You may want to consult a tax or financial advisor.

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If your distribution will be sent to an address outside of the United States, Puerto Rico or the U.S. Virgin Islands, you must

also submit either an IRS Form W-9 to certify you are a U.S. person or a Form W-8BEN if you are a non-resident alien with

respect to the U.S. To obtain these forms or for assistance in determining which form you should submit, please go to the

IRS website at or consult with a tax advisor. If you do not submit one of these forms along with this form, Mercer

will apply 30% tax withholding to your distribution.

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Please return your completed form to:

US Postal Mail (including USPS Express Mail) – Mercer, Attn: IBEW Local No. 8 401(k) Plan, P.O. Box 9740, Providence,

RI 02940-9740.

Other Courier Mail – Mercer, Attn: IBEW Local No. 8 401(k) Plan, Investors Way, Norwood, MA 02062.

1. PARTICIPANT INFORMATION

__________-__________-__________

SOCIAL SECURITY NUMBER

_________________________________________________________________________________________________________

LAST NAME

FIRST NAME

MIDDLE INITIAL

_________________________________________________________________________________________________________

STREET ADDRESS

APT #

_________________________________________________________________________________________________________

CITY

STATE

ZIP CODE

(_______)________-______________

DAYTIME TELEPHONE NUMBER

EVENING TELEPHONE NUMBER

2. DISTRIBUTION AMOUNT

I request a Hardship distribution in the amount of :

The maximum amount available $ ___________________________

The amount of your distribution request should be the exact amount of your financial hardship.

(If you would like the amount of your distribution to include the amount necessary to pay taxes or penalties you expect to result

from the distribution – such as the 10% additional tax on early withdrawals, please check the box below.)

Please adjust the dollar amount I have requested to include the amount necessary to pay taxes or penalties as a

result of this distribution.

3. REASON FOR DISTRIBUTION

I have a financial hardship and need the distribution in order to (check one):

obtain medical care for my spouse, my dependents or myself. (Attach a copy of a medical bill and proof of the

portion not covered by insurance.)

purchase a principal residence for me (not including mortgage payments). (Attach a signed copy of a purchase and

sale agreement.)

pay tuition and related fees for the next 12 months of post-secondary (i.e., after high school) study for my spouse, my

dependent, or me. (Attach a copy of the tuition bill.)

prevent my eviction from my principal residence or foreclosure of the mortgage on my principal residence. (Attach

a copy of the eviction or foreclosure notice that indicates the amount past due.)

pay burial or funeral expenses for my deceased parent, spouse, child or dependent. (Attach a copy of the death

certificate and mortuary bill.)

pay expenses for the repair of damage to my principal residence caused by fire, storm or other casualty. (Attach a

copy of the repair bill, estimate or signed work order for the repair, or a copy of IRS Form 4684.)

I understand that as a condition of my distribution, (1) the amount requested may not be in excess of my immediate financial

need, including amounts necessary to pay any federal, state or local income taxes or penalties reasonably anticipated to result

from the distribution, (2) I have obtained all distributions and non-taxable loans currently available under all of my employer’s

plans and (3) I will be ineligible to make any member contributions to this Plan or any other plan maintained by the union until the

first payroll following 6 months from the date of withdrawal (other than health or welfare plans).

4. FEDERAL INCOME TAX WITHHOLDING ELECTION

As described in the “Special Tax Notice Regarding Plan Payments,” federal income tax will be withheld on the amount of your

hardship distribution at the rate of 10%, unless you elect not to have withholding apply. If you elect no withholding, you are still

liable for any federal income taxes due on the taxable part of your distribution, and you could incur penalties if your withholding

or estimated tax payments for the year are not enough.

Do not withhold federal income tax from the portion of my distribution that is not an eligible rollover distribution.

5. PARTICIPANT SIGNATURE

I request the Hardship distribution indicated above. I have read the “Special Tax Notice Regarding Plan Payments” and I understand

my distribution choices, including my right to defer payments to me under the Plan.

_______________________________________________________________________

________/______/___________

Signature of Participant

Date (MM-DD-YYYY)

CV(14)651051-003 07/07/09

01001HARD651051

Financial Hardship Distribution Form

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