Payroll & Benefit Services
University of Colorado 303-735-6500 Toll Free 877-627-1877 Fax 303-735-6599
FINANCIAL HARDSHIP PBS Application for Approval of Distribution 1. Call the Fund Company to request their Hardship Withdrawal Form. 2. Complete this form (notarize signature), attach the Hardship Withdrawal Form, supporting documentation and a Salary Reduction Agreement (SRA). 3. Submit all to Payroll & Benefit Services, SYS 575, Boulder, CO 80309-0575. Name: _____________________________________________ Street Address: _____________________________________ _____________________________________________________ City/State/Zip Code: ________________________________ Employee ID: _______________________ Social Security No.: __________________ Home Phone: _______________________ Work Phone: ________________________
I affirm that I have an immediate and heavy financial need and I am requesting a hardship distribution of my contributions made to the 403b plan with: ____________________________. The reason for my distribution request is (check appropriate item(s): Medical expenses as defined under the Internal Revenue Code, Section 213 for (check one): ___ me ___ my spouse ___ a dependent. Expenses relating to the purchase of my principal residence. Tuition and related educational expenses for (check one): ___ me ___ my spouse ___ a dependent. Monies needed to prevent (check one): ___ my eviction ___ foreclosure of my mortgage The total amount of my financial need is $ __________. I am requesting a distribution of $ __________. Attached is the necessary documentation to support my request (i.e., eviction notice, tuition bill, etc.). I certify that I have carefully considered all alternative means of meeting this financial need and have determined that the need cannot be met by any of the following: Through reimbursement or compensation by insurance or otherwise; by reasonable liquidation of my other assets; by stopping employee contributions under the plan; by other distributions or loans from plans maintained by the employer or any other employer; by borrowing from commercial sources on reasonable commercial terms. I understand that the income tax effect of any distribution is my responsibility to determine and satisfy. Per the Internal Revenue Code, I understand I cannot contribute to a 403(b)/401(k)/457 for a period of at least six months. I verify I have completed the SRA to stop my current contributions to any tax deferred annuity at the University of Colorado and will complete a new SRA to begin contributions after six months or at a later date. _________________________________________________ Signature of Employee Subscribed and sworn to before me on This ________ day of ________. _______________________________ Notary Public
11/10/03
___________________________________ Date For PBS Use Date Received: ___________________ Processed by: ____________________ Received SRA Terminated TDA Contribution Reviewed by: _______ Date: _______