401(k) Hardship Withdrawal Request State of Tennessee 401(k ...

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Last Name First Name MI Social Security Number❑ Principal Residence Repair - expenses for repair of damage to the employee’s principal residence that qualifies for the casualtydeduction (as defined in IRC 165, determined without regard to whether the loss exceeds 10% of adjusted gross income) if permittedby the PlanRequired Documentation - Copies of invoices and/or receipts showing the cost of repair after taking into account anyreimbursement from your insurance company. For the insurance information, include a statement from the insurance company.Hardship AmountThe withdrawal will be prorated across all available money sources available for hardship withdrawals under your Plan.If the amount requested exceeds available funds or exceeds limits imposed by IRC, regulations and/or Plan terms, we will process thehardship for the maximum amount available.$ ❑ Net AmountDistribution Delivery❑ Check❑ Express Delivery - $25.00 non-refundable charge will be deducted from your distribution amount. If both Non-Roth and Rothmoney sources are allowed by your Plan and distributed, $25.00 will be deducted from each check, totaling $50.00. Express deliveryavailable Monday through Friday only. Check will be sent by USPS Express if address is a P.O. Box and could take 2-3 businessdays for delivery.❑ ACH - $15.00 non-refundable charge will be deducted from your distribution amount. ACH credit can only be made into a UnitedStates financial institution. Any requests received referencing a foreign financial institution or referencing a United States financialinstitution with a further credit to an account associated with a foreign financial institution will be rejected. If both Non-Roth andRoth money sources are allowed by your Plan and distributed, $15.00 will be deducted from the Non-Roth and Roth moneysources, totaling $30.00.❑ Checking Account - must attach preprinted voided check❑ Savings Account - must attach a letter on financial institution letterhead signed by a representative of the financial institution thatincludes your name, savings account number and ABA routing numberFinancial Institution Name Account Number ABA Routing NumberFinancial Institution Mailing Address City State/Zip Code][Form 11 ][GWRS FDSTHD ][12/07/12 ][Page 2 of 6][GP22][/306025589][A01:112912
Last Name First Name MI Social Security NumberAddress Change/Alternate Mailing Address❑ Principal Residence Address Change - I understand that a check made payable to me requested on this form will be mailed to mynew primary address I provided on this form.For Active Employees Only - I understand that it is my responsibility to update my address with my employer in addition tochanging my primary address on this form. Failure to do so will/may result in my address being incorrect on Service Provider’srecords. A current address is essential for correspondence and tax purposes.Address - Number & Street City State Zip Code❑ Alternate Mailing Address - I understand that this address will be used for this distribution only.Address - Number & Street City State Zip CodeIf you request an address change that is submitted the same day this request is submitted, or if you are requesting an alternatemailing address, you must have your signature notarized or witnessed by your Plan Administrator. The date you sign belowmust match the date on which your signature was notarized or witnessed by your Plan Administrator.Participant SignatureDateStatement of NotaryNOTE: Notary seal must be visible, if applicable.State of ) This request was subscribed and sworn to (or affirmed) before me on this day) ss. of , year , by (name ofCounty of ) participant) who proved to me on the basis of satisfactory evidence to be the person who appeared before me.SEALNotary Public-OR-Statement of Plan AdministratorMy commission expiresI certify that the participant signed the Address Change/Alternate Mailing Address section in my presence.Plan Administrator SignatureDateFederal and State Income Tax Withholding - Applies to all applicable money sourcesFederal Income Tax - Federal income tax will be withheld at the rate of 10%, unless Service Provider is directed otherwise below.If you would like additional federal income tax withheld, indicate amount $ or % of the distributionamount.❑ Do NOT withhold federal income tax from my hardship distribution.State Income Tax - If you live in a state that mandates state income tax withholding, it will be withheld.❑ Check here if you live in a state that does not mandate state income tax withholding and would like state income tax withheld.If you would like additional state income tax withheld, indicate amount $ or % of the distributionamount.][Form 11 ][GWRS FDSTHD ][12/07/12 ][Page 3 of 6][GP22][/306025589][A01:112912
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401(k) Hardship Withdrawal Request State of Tennessee 401(k ...

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