401(k) Profit Sharing Plan NOTICE OF HARDSHIP WITHDRAWALS Participant:_______________________________________________ Amounts that have been contributed on your behalf as salary reductions may be withdrawn if you have an immediately and heavy financial need. An immediate and heavy financial need can arise for one of the following reasons: Medical expenses which you, your spouse or dependents incur or are necessary for you, your spouse or dependents to obtain medical care. These must be expenses described in Section 213 of the Internal Revenue Code; Purchase of your principal resident; Payment of tuition, related educational fees, and room and board expenses for the next twelve (12) months of post-secondary education for you, your spouse, children or dependents; or Prevent your eviction from your principal residence or foreclosure on your principal residence. Also, in order to qualify for a withdrawal, you must have no other resources or savings to take care of the immediate and heavy financial need. Under special IRS rules you will be considered to not have sufficient resources to meet the immediate and heavy financial need only if: The hardship distribution we make to you is not in excess of the immediate and heavy financial need; You have already obtained all distributions (other than a hardship distribution) and non-taxable loans available from any plan we maintain; and You agree not to make salary reduction contributions for at least six (6) months after you receive the hardship distribution. If you receive a hardship distribution during 2002, you are prohibited from making elective contributions and employee contributions for at least (6) months after our receipt of the hardship distribution. If you wish to apply for a hardship distribution, you should fill out an application which the Plan Administrator will provide. Return the application to the Plan Administrator. _____________________________ Plan Administrator ____________________________________ Signature of Participant
Application for Hardship Withdrawal
Participant:______________________________________________________________ Hardship withdrawal amount: $_____________________ Form of distribution:_______________________________________________________
As a participant, I hereby apply for a hardship withdrawal. I confirm that the reason for the hardship is: ( ) ( ) ( ) to pay medical expenses for me, my spouse or dependents to purchase my principal residence to pay tuition, related educational fees, and room and board expenses for the next twelve (12) months of post-secondary education for me, my spouse or dependents to prevent foreclosure on my principal residence or eviction from my principal residence
( )
Having designated the reason for requesting a hardship distribution by checking one or more of the options above, I understand that I must also demonstrate that I have no other resources available to me to meet this hardship. I can do this by meeting the criteria set forth below. I agree that in order to receive the hardship distribution requested above: That the distribution will not be in excess of the immediate financial need ($____________, enter amount) That I have previously obtained all distributions and non-taxable loans available under all retirement plans maintained by the Employer; and That I will not be able to make salary reduction contributions for six (6) months after I receive a hardship distribution Explanation of Qualified Annuity Benefit. Unless you elect otherwise, the Plan must pay certain distributions in the form of a Qualified annuity Benefit. If you are married, the Qualified Annuity Benefit payable from your “participant’s transfer/rollover account” subject to the Qualified Annuity Benefit rules is a joint and 50% survivor annuity. A joint and 50% survivor annuity is a level monthly payment for your life and, if your spouse survives you, a level monthly payment for your spouse equal to 50% of the
monthly amount payable during your joint lives. If you are not married, the Qualified Annuity Benefit is a life annuity. A life annuity is a level monthly payment for your lifetime, with monthly payments stopping upon your death. These payments are guaranteed for your lifetime and, if you are married, your spouse’s lifetime. If you elect a withdrawal from the Plan, you must waive the Qualified Annuity Benefit for that portion of your vested account balance. However, this waiver does not affect the payment of the Qualified Annuity Benefit for the remaining portion of your vested account balance. Each withdrawal you make from the Plan reduces the amount you could have available, after you separate from service, to provide q Qualified Annuity Benefit. Representations: I understand: My election is irrevocable My election serves as a waiver of the Qualified Annuity Benefit only for the portion of my account balance I am withdrawing The Plan will hold the portion of my account balance which I am not withdrawing until I otherwise would receive a distribution of my account balance under the Plan, generally upon my termination of employment. I should consult my own tax advisor with respect to the proper method of reporting any distribution I receive from the Plan. Waiver of minimum notice period. I consent to an immediate distribution of the elected portion of my vested account balance. I affirmatively waive any unexpired portion of the minimum 30-day notice period during which I may consent to a distribution from the Plan. I understand that the Plan Administrator will consider my request within a reasonable time, and I agree to provide any additional information which the Plan Administrator may require. EXECUTED this ____________day of _____________, 200 _________. ____________________________Signature of Participant ____________________________Social Security Number
Consent of Spouse I, ____________________________, spouse of the Participant hereby consent to the waiver of the Qualified Annuity Benefit and to the timing and form of distribution elected on this form. I have received a written explanation of the Qualified Annuity Benefit, my right not to consent to this waiver election, the waiver lection period, and the financial effect of the election not to receive benefits in the Qualified Annuity Benefit form. I understand my consent is irrevocable unless my spouse revokes the waiver election. I understand any change in this form of benefit election is subject to y consent, unless my spouse elects to receive the Qualified Annuity Benefit. EXECUTED this _______________day of ________________, 200 _____. _______________________________Signature of Participant Note: If the spouse completes the above, a proper witness must complete Witness by Plan Representative or Witness by Notary. Witness by Plan Representative Signature of spouse witnessed this ___________day of ____________, 200 _____. ________________________________Plan Representative OR Witness by Notary State of _______________ County of ___________________ Before me, the undersigned, a Notary Public, personally appeared __________________ who executed the above Consent of Spouse as a free and voluntary act. IN WITNESS WHEREOF, I have signed my name and affixed my official notarial seal this ____________ day of ____________, 200_______. (SEAL) Notary Public______________________________ My Commission expires______________________