**PLEASE COMPLETE THE IN-SERVICE WITHDRAWAL FORM AND ATTACH**
Participant’s Name ________________________________________________________
Social Security No. ___________________________________________ Activity Fund Number: _____________________
I request a plan distribution of $ _____________________ due to hardship for the following reason:
Medical Expenses that I (or my spouse or dependent) have incurred, to the extent not reimbursed by
insurance, or need to pay prior to obtaining medical care.
Purchase of My Home – cost directly related to the purchase of principal residence (excluding
Expenses to repair damages to principal residence.
Tuition and Related Education Fees, including lab fees, for the next 12 months for post-secondary
education for myself, my spouse, my children or my dependent.
Funeral Expenses that I am directly responsible for paying.
Prevention of Eviction or Foreclosure on my primary residence.
A copy of the bill must be attached to this form (or other document describing the expense and the amount). If
the expense is for someone other than the Participant, list person and relationship on the document.
Other Resources: Under penalty of perjury, I represent that the above hardship expense cannot be met by
any other reasonable available source, including (1) reasonable liquidation of, my spouse’s or my minor
children’s assets such as cash, bank accounts, stocks, securities, and any other investments and property
(without creating an additional financial need); (2) distributions and non-taxable loans from other retirement
plans or by borrowing from commercial sources on reasonable commercial terms; (3) reimbursement or
compensation by insurance or otherwise; and (4) suspension of elective contributions or employee
contributions under the plan.
Consequence of Withdrawal: I understand that (1) my elective deferrals (pre-tax) and my employee
contributions (after-tax) to this plan and all other plans maintained by the Employer will be suspended for 6
months after the hardship withdrawal is made, and (2) the following taxable year, I will be limited in making
Before-Tax Contributions to this plan and all other plans maintained by the Employer to no more than the
elective deferral limit for that year minus my Before-Tax Contribution made in the taxable year of the
Participant Signature Date
Personnel Representative Signature Date