ASC HARDSHIP FORM

A copy of a valid government issued photo identification is required to process this request.

If you elect to receive this request as a direct deposit/ACH, attach a voided check or bank statement that contains the valid routing number and bank number.

Incomplete submissions will not be accepted.

Employer / Plan Name*

Employer / Plan Name 2

Your Name*

First NameLast Name

Your Name 2

First NameLast Name

Social Security*

Social Security 2

Address*

Mailing Address (Street Address, P.O. Box, etc.)

Street Address Line 2

CityState / Territory

Postal / Zip Code

Contact Number(s):*

E-mail Address:*

Date of Birth*

Not MarriedMarried

Guam (Rev & Tax)U.S. (IRS)CNMI (DRT)Other

INSTRUCTIONS

•You must certify that you have an immediate and heavy financial need that necessitates a hardship withdrawal (section A below).

•You must certify that you have no other source of funds to cover this hardship expense (section D below).

•The amount you request cannot be greater than what is required to satisfy the financial need plus what is required to pay the taxes and penalties you owe as a result of the withdrawal.

•There may be restrictions on what money you can withdraw. For example, you cannot withdraw Retirement account earnings made after December 31, 1988. Please refer to the Summary Plan Description or Plan Document for specific requirements.

•There is a $50.00 check processing or ACH fee for distributions

I understand that a withdrawal of salary deferrals will be considered due to financial hardship only to the extent that the amount of the withdrawal is necessary to satisfy an immediate and heavy financial need. I understand that this withdrawal will be taxed as ordinary income in the year in which it is received, and may also be subject to state taxes (where applicable). In addition, a 10% penalty tax will apply unless I am at least 59½ years of age or I use the funds withdrawn to pay certain deductible medical expenses as provided by law. The IRS allows the following reasons for taking a hardship withdrawal in the Plan. Please check ONE of the options below to describe your financial hardship need.

Purchase of my primary residence, excluding mortgage payments, refinancing, and loans for purchase of land only.Payments necessary to prevent eviction from or foreclosure on the mortgage of my primary residence.Payment for the next 12 months of tuition (and related education fees) of post-secondary education for me, my spouse, children, qualifying dependents, or primary beneficiary.Payment of necessary medical expenses incurred by me, my spouse, children, qualifying dependents, or primary beneficiary to the extent not reimbursed by insurance.Outstanding balance due for the burial or funeral expenses for my parent, spouse, children, qualifying dependents, or primary beneficiary.Payments for the repair of damage to my principal residence that would qualify for the casualty deduction under Code section 165 (regardless of whether the loss exceeds 10% of my adjusted gross income).

I hereby request a withdrawal of salary deferrals of the type elected above. I have read the above language and understand the tax implications of this withdrawal. I wish to withdraw the amount indicated below.

The following amount: $ net. (Certain restrictions may not allow you to withdraw the full amount requested.)

I want 10% withheld from my distribution for income taxesI want 20% withheld from my distribution for income taxesI do not want taxes withheld from my distribution. I understand that I will be liable for income taxes at the year end when I file my income tax return.

Check payable to me.I would like an automatic deposit to my bank account (ACH). I have attached a deposit slip or voided check that contains the valid routing number and bank account number.

Bank Name:

Savings AccountChecking Account

Account Number:

Routing Number:

Account Number:

Routing Number:

Attach VOIDED Check Here

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Certification: I certify that the need indicated in Section A is true, that the amount requested on my Hardship Request Form does not exceed the amount of this need plus taxes and penalties, and that I have obtained all other withdrawals and loans available under my Company-sponsored Retirement Plan. As a condition of receiving a hardship distribution, I certify that I have insufficient cash or other liquid assets reasonably available to satisfy the hardship need. I also understand that the maximum amount I can contribute next year cannot exceed next year's legal limit minus the amount I contributed this year (if any).

A valid photo ID must be attached to this request*

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A Hardship Supporting Document must be attached to this request*

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Signature or Participant*

Date*

Date

A copy of a valid government issued photo identification is required to process this request.

If you elect to receive this request as a direct deposit/ACH, attach a voided check or bank statement that contains the valid routing number and bank number.

Incomplete submissions will not be accepted.

ASC HARDSHIP REQUEST FORM

General Information

A. Reason For Withdrawal Request

B. Withdrawal Amount

C. Payment Instructions