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.

Employer / Plan Name *

Name

First Name Last Name

Name

First Name Last Name

Social Security Number

Mailing Address *

Street Address

Street Address Line 2

City State / Territory

Postal / Zip Code

Contact Number *

Please enter a valid phone number.

Alternative Contact Number

Please enter a valid phone number.

E-mail Address *

example@example.com

Date of Birth *

Date

Marital Status: *

Married Not Married

I will be filing this year's income taxes in

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 ( 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.

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 the amount indicated below. I have read the above language and understand the tax implications of this withdrawal. *

NET (If your Plan does not allow you to withdraw the full amount requested, the maximum amount available will be distributed to you.)

Tax Withholding (Optional): *

I want 10% withheld from my distribution for income taxes. I want 20% withheld from my distribution for income taxes. I 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.

I elect for the withdrawn amount to be paid to me in the form of a: *

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

Type of Account

Savings Checking

Bank Account #

Savings

ABA Routing #

Savings

Bank Account #

Checking

ABA Routing #

Checking

Attach VOIDED Check Below

By electing a Direct Deposit (ACH) and by signing below, I hereby authorize ASC TRUST LLC 1) to initiate credit entries to the depository financial insitution named above 2) to initiate debit entries to adjust for processing errors. I understand that a $30.00 fee will be charged to my payout for any ACH payments rejected due to closed bank account or erroneous bank account info provided to ASC. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law.

A valid photo ID must be attached to this request. *

A Hardship Supporting Document must be attached to this request. *

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.

Signature *

Clear

Date *

Date

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.

Hardship Request Form

General Information

A. Reason for Withdrawal Request

B. Withdrawal Amount

C. Payment Instructions

DOCUMENTS REQUIRED FOR HARDSHIP WITHDRAWALS