Distribution Financial Hardship
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Distribution — Financial Hardship
Use this form to request a one-time cash distribution for hardship reasons from your 401(a), 401(k), 403(b), or 457(b) governmental
employer plan. Available for current employees only. Fill in by hand using CAPITAL letters and black ink, or on screen (if PDF). If you need
more room for information, use a copy of the relevant page.
Helpful To Know
• You can only take a distribution if you meet one of the
• For most other types of distributions (such as cash or roll-
criteria for eligibility (see Section 3).
over) find the appropriate forms at
• Workplace retirement plan distributions may have
• Non-resident aliens must provide IRS form W-8BEN and a
U.S. taxpayer ID number to claim any tax treaty benefits.
tax consequences. You may want to consult a tax or
financial professional.
• Be sure to keep the documentation you provide in
• Hardship withdrawals may require documentation
connection with your hardship request for at least six
and plan sponsor approval.
years after your distribution check arrives.
• To get your plan number(s), call your plan sponsor
• Before you submit this form, be sure to find out whether
(the employer that provides the plan) or go to
your plan requires plan sponsor approval of distribution
.
requests. If your plan does, and there is no plan sponsor
signature in Section 9, your request will be denied.
• To validate your profile, go to
To change your address, call your plan sponsor or go to
1. Account Owner / Participant
Name
Social Security or Taxpayer ID Number
Date of Birth
Evening Phone
Daytime Phone
mm – dd – yyyy
E-mail
Not married
Married
your spouse may need to sign this form. Ask your plan sponsor or Fidelity.
If the address we have for you is correct, skip to Section 2.
Address
Providing a new
address may delay
your check unless you
City
State/Province
Zip/Postal Code
Country
get a signature guar-
antee (see Section 8).
2. Plan Involved
Name of Plan Sponsor
Plan Number
To get your plan
num ber, go to
mysavings
or call your
plan sponsor.
Form continues on next page.
3.TEMDISTFH.104
026370201
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