403 B Hardship Authorization Form - Jefferson County Schools (Page 2 of 2) in pdf

403(b) Hardship Documentation Guidelines

General

The Plan and IRS define certain circumstances that can qualify for a hardship distribution from the Plan if you have exhausted all other sources of

assets including loans. These are the only circumstances under which you may qualify for a hardship under the Plan. Evidence of the hardship

must be provided to document both the nature of the hardship and the amount of the hardship. As a general rule, documentation should be current,

dated, and as descriptive as possible.

Eligible Hardship Reasons:

Allowable Expenses: Tuition, fees, and room and board for up to the next 12 months of post-secondary education (such as through a university,

college, or technical school) for you, your spouse, or dependent. Note that post-secondary expenses for education already obtained does not

Post-

qualify.

Secondary

Documentation Required: Tuition bill or financial statement from the institution that details the actual or estimated costs, fees, and expenses. If

Education

room and board expenses are also requested, a statement from the landlord or residence hall. The dates of semesters or educational period should

be identified.

Allowable Expenses: Costs directly related to the purchase of your principal residence such as a down payment or closing costs. Mortgage

Purchase of

payments are not eligible.

Primary

Documentation Required: A statement from the mortgage company, realtor, or builder detailing the amounts of the down payment or closing

Residence

costs. Commonly, this information is included in a “good faith estimate” provided by the lender. An estimated closing date should be provided.

Allowable Expenses: Amounts needed to prevent eviction from your primary residence or amounts needed to prevent foreclosure on your primary

Prevent

residence.

Eviction or

Documentation Required: Current written statement or notice from landlord, bank, or mortgage company detailing amounts due necessary to

Foreclosure

prevent the eviction or foreclosure.

Allowable Expenses: Cost of medical or dental expenses for you, your spouse, or dependent that is not otherwise covered by insurance. Note

that elective procedures, including most orthodontics, are not eligible.

Health

Documentation Required: Recent bill or explanation of benefits (EOB) from your insurance provider identifying the portion of expenses that are

Expenses

your responsibility. If upfront payment is required to obtain medical care, a statement from the provider with an estimate of the costs to the patient.

Documentation should include dates of service and explanation of services provided.

Allowable Expenses: Burial or funeral expenses for your parent, spouse, child, or dependent.

Funeral

Documentation Required: Statement from the funeral director or cemetery identifying the services and costs together with the deceased name,

Expenses

date of death, and date of funeral or burial.

403 B Hardship Authorization Form - Jefferson County Schools Page 2

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