Distribution Financial Hardship (Page 2 of 4) in pdf

3. Reason for Distribution

Required by federal tax law and your plan.

401(a), 401(k), 403(b)

Check ONLy one.

Some plans do not

Purchase of primary residence

Cannot be used for mortgage payments.

accept all of the

Prevent primary residence foreclosure or eviction

hardship distribution

reasons listed here,

Repairs to primary residence

ONLy for repairs that would have qualified for the IRS casualty deduction.

and others offer addi-

Pay for tuition or related fees for post-secondary education during the next 12 months

ONLy for you, your spouse, your

tional reasons.

dependent, or if your plan allows, your already-designated primary beneficiary.

Contact your plan

Funeral expenses

ONLy for your spouse, your dependent, or, if your plan allows, your already-designated primary beneficiary.

sponsor to confirm

which reasons your

Medical expenses not covered by insurance

ONLy for you, your spouse, your dependent, or if your plan allows, your

plan accepts, what

already-designated primary beneficiary.

documentation it

Other

Not available for most plans. Requires approval of the plan sponsor if available from your plan.

requires, and whether

you qualify.

457(b)

ONLy

Unforeseen emergency

Requires approval of the plan sponsor.

4. Distribution Amount

If your request exceeds your avail able plan assets or the amount your plan approves for your hardship, we will send the allowed/available

amount minus any applicable tax withholding. Your available plan assets may be less than your plan value. Tax withholding may apply. Use

reasonable estimates for any taxes or penalties due when calculating the amount below.

Amount

Draw proportionally from ALL available plan assets

default if no choice indicated.

Draw ONLY from these assets:

distribution amount will be limited by available plan assets in the fund(s) listed below and by market fluctuation.

Fund Name or Number

If you list more than

one fund, your distri-

bution will be drawn

Fund Name or Number

proportionally from

each fund listed.

5. Tax Withholding

The IRS does not require us to withhold taxes on a hardship distribution. However, if you do not indicate a selection below, we will default

to withholding taxes. Each state sets its own withholding rates and requirements on taxable distributions. We apply these rates unless you, or state

law, direct otherwise.

For residents of CT, NY, NM, NJ, ND, PA and RI, you must provide a dollar amount for state withholding if you would like it withheld ($10 minimum),

otherwise no amount will be withheld.

For U.S. Persons the default withholding rate of 10% will apply. For non-resident aliens, the minimum federal mandatory withholding rate of 30%

will apply, unless the prevailing tax treaty rate applies because you have a valid IRS Form W-8BEN on file with Fidelity.

Note that the amount of tax withheld will be calculated on, and subtracted from, the amount of your distribution. Amounts withheld may be less

or more than what you actually owe in taxes. To review the Special Tax Notice for details, go to

Federal

State Withholding

Withhold federal taxes at the rate of:

Withhold state taxes at the applicable rate

Account’s legal /

Note that if there is federal withhold-

In addition to the applicable rate, withhold a

Percentage (10% minimum)

residential address

ing, certain states require that there

dollar amount of:

determines which

.0%

also be state withholding.

state’s tax rules apply.

Withhold ($10 minimum)

Do NOT withhold federal taxes

Residents of CT, NY, NM, NJ, ND, PA and RI ONLY.

Withhold state taxes in the amount of:

Withhold ($10 minimum)

Do NOT withhold state taxes unless required by law

Form continues on next page.

3.TEMDISTFH.104

026370202

Page 2 of 4

Distribution Financial Hardship Page 2

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