Hardship Request Form

The following documents must be submitted in order to process:

• This form, completed and signed
• Hardship supporting documents
• A valid photo ID, such as Driver's License or Passport
• If payment is to be sent electronically (via ACH), provide a voided check or letter from your bank on bank letterhead with your name, routing number, account number, and account type (checking or savings).

Incomplete submissions will not be accepted, and all documents will need to be re-submitted.

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 ( see Certification 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. 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 may apply on amounts eligible for rollovers unless I am at least 59½ years of age (some exceptions apply). The IRS allows the following reasons for taking a hardship withdrawal in the Plan.

Certification: I certify that the reason indicated in Section A of this Form is true, that the amount requested in Section B of this Form does not exceed the amount of this hardship plus taxes and penalties, and that I have obtained all other withdrawals available under all retirement plans maintained by my Employer. As a condition of receiving a hardship distribution, I certify that I have no other resources, including cash or other liquid assets, available to me to meet this hardship. Further, I understand that I must be able to provide supporting documentation or information that supports my request for a hardship distribution, if requested.

The following documents must be submitted in order to process:

• This form, completed and signed
• Hardship supporting documents
• A valid photo ID, such as Driver's License or Passport
• If payment is to be sent electronically (via ACH), provide a voided check or letter from your bank on bank letterhead with your name, routing number, account number, and account type (checking or savings).

Incomplete submissions will not be accepted, and all documents will need to be re-submitted.

The reason for the hardship must be immediate in nature and a heavy financial burden. Other allowable withdrawals under all the Employer's retirement plans must be exhausted before applying for a hardship withdrawal.

Participants are responsible for submitting documentation to support the need for a plan withdrawal. Supporting documents are required before the request can be processed.

PURCHASE OF PRINCIPAL RESIDENCE - To show proof of purchase, provide a copy of the signed (by both buyer and seller) purchase agreement of a principal residence or land purchase contract for the construction of a principal residence, along with a letter or agreement of approved financing. Proof of financing can include a good faith estimate of mortgaged amount, or if through an individual, a notarized agreement stating the loan amount and that the purpose is for the purchase of a principal residence. Closing date on the purchase must be a date that has not yet occurred.

EVICTION FROM OR FORECLOSURE OF PRINCIPAL RESIDENCE - principal residence is defined as a home, mobile home, apartment, or condominium where the participant currently resides.

Letter from a mortgage company, notarized statement from an individual (if renting from an individual), or statement on company letterhead (if renting from a company) giving notice, as required under applicable law, that if the overdue rent or mortgage payment were not received by a specified deadline, formal eviction or foreclosure proceedings will be instituted. The deadline must be a date that has not yet occurred.

EDUCATION EXPENSES – unreimbursed post-secondary education expenses at a state-accredited school for the next 12 months for participant, spouse, or dependents considered for hardship.

Bill from educational institution or letter verifying active enrollment or pending enrollment of participant or dependent that specifies name of stu- dent, associated costs, and date bill due. This is to include estimated costs of tuition, fees, room, board, and related expenses. In addition, a copy of your tax document must also be submitted.

MEDICAL EXPENSES – unreimbursed expenses incurred for participant, spouse, or dependents that qualify under Section 213(d) of the IRC are allowable.

Health care provider bill, along with insurance company benefit statement denying coverage for at least the amount being requested, and due date for bill or other statement from the health care provider stating amount paid by insurance company and that the amount due is participant’s responsibility, and due date. If the expense has not yet been incurred, a signed letter from a doctor or other health care provider verifying the need for treatment and the approximate cost. Actual expenses should be submitted after expense has been incurred. In addition, a copy of your tax document must also be submitted.

BURIAL OR FUNERAL EXPENSES – outstanding balance due for burial or funeral expenses for a deceased parent, spouse, child, sibling or qualifying dependent are allowable.

Death certificate and outstanding bill from funeral home or institution showing the costs of burial or funeral and the date due. Statement indicating relationship to deceased is also required.

REPAIR OF PRINCIPAL RESIDENCE QUALIFYING AS A CASUALTY DEDUCTION – unreimbursed expenses for the repair of damage 1 caused by storm, fire, or other casualty that qualify under Section 165 of the IRC are considered for hardship. Principal residence is the single-family home, townhouse, condominium, or mobile home where the participant resides.

Evidence of casualty (a description or description, and photograph), repair bill, and proof that insurance proceeds did not cover the casualty ex- pense claimed as a hardship, and statement of deductibility providing valuations immediately before and after casualty.