Last Name First Name MI Social Security NumberSignature and ConsentParticipant ConsentAny person who knowingly presents a false or fraudulent claim is subject to criminal and civil penalties.My signature acknowledges that I have received, read, understand and agree to all pages <strong>of</strong> the <strong>401</strong>(k) <strong>Hardship</strong> <strong>Withdrawal</strong> <strong>Request</strong>form and affirms that all information I have provided is true and correct. I affirm I have taken all distributions other than hardshipdistributions and all nontaxable loans (to the extent such loans do not cause a hardship to me) under the Plan and all other qualifiedplans <strong>of</strong> the employer. I understand that deferrals (contributions) under the Plan must cease for a period <strong>of</strong> at least 6 months. Byrequesting my distribution via ACH deposit, I certify, represent and warrant that the account requested for an ACH deposit isestablished at a financial institution or a branch <strong>of</strong> a financial institution located within the United <strong>State</strong>s and there are no standingorders to forward any portion <strong>of</strong> ACH deposit to an account that exists at a financial institution or a branch <strong>of</strong> a financial institution inanother country. Service Provider reserves the right to reject the ACH request and deliver any payment via check in lieu <strong>of</strong> directdeposit. I understand that funds may impose redemption fees on certain transfers, redemptions or exchanges if assets are held less thanthe period stated in the fund’s prospectus or other disclosure documents. I will refer to the fund’s prospectus and/or disclosuredocuments for more information. I understand that Service Provider is required to comply with the regulations and requirements <strong>of</strong> theOffice <strong>of</strong> Foreign Assets Control, Department <strong>of</strong> the Treasury ("OFAC"). As a result, Service Provider cannot conduct business withpersons in a blocked country or any person designated by OFAC as a specially designated national or blocked person. For moreinformation, please access the OFAC Web site at:http://www.treasury.gov/about/organizational-structure/<strong>of</strong>fices/Pages/Office-<strong>of</strong>-Foreign-Assets-Control.aspx.Under penalty <strong>of</strong> perjury, I certify that my Social Security number (or a Taxpayer Identification Number) as shown on the first page <strong>of</strong>this request is correct, and that I am a U.S. person if I checked the U.S. Citizen box or the U.S. Resident Alien box on this withdrawalrequest form.I understand that I am liable for any income tax and/or penalties assessed by the IRS for any election I have chosen. I understand thatonce my payment has been processed, it cannot be changed. In the event that any section <strong>of</strong> this form is incomplete or inaccurate,Service Provider may not process the transaction requested on this form and may require that I complete a new form or provideadditional or proper information before the transaction can be processed.I agree and elect that my salary deferral (contribution) be set to 0% at the same time that this distribution is processed. I understand Imust request my deferrals (contributions) to begin again once the suspension period has expired except and in accordance with otherPlan rules.Participant SignatureDate (Required)Participant forward to Service Provider at:Great-West Retirement Services®PO Box 173764Denver, CO 80217-3764Express Address:8515 E. Orchard Road, Greenwood Village, CO 80111Phone #: 1-800-922-7772Fax #: 1-866-745-5766][Form 11 ][GWRS FDSTHD ][12/07/12 ][Page 4 <strong>of</strong> 6][GP22][/306025589][A01:112912
<strong>Hardship</strong> <strong>Withdrawal</strong> CertificationThe Internal Revenue Code (the "Code") imposes restrictions on the availability <strong>of</strong> before-tax monies from <strong>401</strong>(k) plans until theoccurrence <strong>of</strong> one <strong>of</strong> the following: attainment <strong>of</strong> age 59 1/2; or severance <strong>of</strong> employment (due to total disability, retirement orotherwise); or financial hardship as determined under present or future IRS regulations (if allowed by the Plan); or death <strong>of</strong> participant;or any other reason specifically allowed under the provisions <strong>of</strong> the Plan in which you are a participant.Pursuant to the Code, the amount distributable upon hardship is limited. The distributable amount is limited to the employee’s totalelective deferrals as <strong>of</strong> the date <strong>of</strong> distribution, reduced by any previous hardship distributions. Further, if the Plan allows, thedistributable amount may be increased by 1) employer contributions; and 2) the earnings allocable to the elective deferrals that werecredited to your account no later than December 31, 1988 or the end <strong>of</strong> the last Plan year ending before July 1, 1989, whichever islater.The amount you request for hardship may not exceed the amount <strong>of</strong> your financial need. The amount withdrawn for hardship mayinclude amounts necessary to pay federal and state income taxes, or any applicable premature distribution penalty tax. Unless the NetAmount box has been selected, the amount you request will be a gross amount; that is, federal and/or state income tax will be withheldfrom your requested amount.Amounts transferred from your prior carrier will not be available for hardship withdrawals unless Service Provider has received a reportfrom the prior carrier or the Plan Administrator showing the amounts available for hardship withdrawal. If regular payroll contributionshave not been received, the amount available for hardship withdrawal may be zero.Safe Harbor - Your Plan may allow for a hardship distribution based on a Safe Harbor test.A distribution is deemed to be for an immediate and heavy financial need if it is made for any one or a combination <strong>of</strong> the reasonsspecified in the <strong>Hardship</strong> Reason section on Page 1 <strong>of</strong> this form. In addition to the rules enumerated above, a Safe Harbor hardshipdistribution is subject to the following additional rules:The participant may have been required to receive all distributions (other than hardship distributions), and all available nontaxable loans,from this and all other plans maintained by the employer (including a related employer).<strong>Hardship</strong> Approval and Effective Date - Before processing your hardship withdrawal request, Service Provider must first receive allrequired documentation. This request cannot be approved without pro<strong>of</strong> <strong>of</strong> financial hardship. If any documentation is missing, yourrequest will be rejected and will not be processed until you submit the required documentation with a copy <strong>of</strong> your <strong>Hardship</strong><strong>Withdrawal</strong> <strong>Request</strong> form. The effective date <strong>of</strong> your hardship withdrawal request will not be until after the hardship approval.Express Delivery - The amount <strong>of</strong> your distribution check will be reduced by $25.00 for this service. 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 delivery isonly available Monday through Friday. Check will be sent by United <strong>State</strong>s Postal Service Express if address is a P.O. Box and couldtake 2-3 business days for delivery. Delivery is not guaranteed to all areas.Automated Clearing House (ACH) - Check this box and complete this section only if you want your payment to be electronicallydeposited into your checking or savings account. You may not designate a business account, an IRA or any other retirementplan/account. Your distribution amount will be reduced by $15.00 for this service. ACH credit can only be made into a United <strong>State</strong>sfinancial institution (bank/credit union). If both Non-Roth and Roth money sources are allowed by your Plan and distributed, $15.00will be deducted from the Non-Roth and Roth money sources, totaling $30.00.Complete the financial institution name, account number, ABA routing number, financial institution mailing address, city, state and zipcode. For a checking account, you must attach a preprinted voided check. If a preprinted voided check is not available, you must attacha signed letter from your financial institution, on their letterhead, that confirms the ABA routing number and your name and accountnumber. For a savings account, you must attach a letter on financial institution letterhead signed by a representative <strong>of</strong> the financialinstitution that includes your name, savings account number and ABA routing number.General ACH InformationBy choosing an ACH credit to your financial institution account, you are authorizing Service Provider to initiate a credit entry and, ifnecessary, a debit entry if an error should occur. You are also authorizing your financial institution, in the form <strong>of</strong> an electronic fundstransfer, to credit and/or debit the same to such account. Service Provider will make your payment in accordance with the directionsyou have specified on the <strong>Hardship</strong> Form.If your financial institution rejects the ACH credit, Service Provider will make every attempt to fix the error and process the request.However, if Service Provider is still unable to send the ACH credit, a check will be mailed to the address that is on file with theService Provider.By selecting an ACH method <strong>of</strong> delivery, you acknowledge that Service Provider is not liable for the payment made by ServiceProvider in accordance with a properly completed <strong>Hardship</strong> Form. By selecting this method <strong>of</strong> distribution delivery, you are authorizingand directing your financial institution not to hold an overpayment made by Service Provider on your behalf, or on behalf <strong>of</strong> yourestate or any current or future joint accountholder, if applicable.ACH delivery is not available to a foreign financial institution or to a United <strong>State</strong>s financial institution for subsequent transfer to aforeign financial institution. Any requests received containing foreign financial institution instructions will be rejected and require newACH or Check delivery instructions.It is your obligation to notify Service Provider <strong>of</strong> any address or other changes affecting your electronic fund transfers. You are solelyresponsible for any consequences and/or liabilities that may arise out <strong>of</strong> your failure to provide such notification.Income Tax Withholding Applicable to Payments Delivered Outside the U.S.If you are a U.S. citizen or resident alien and your payment is to be delivered outside the U.S. or its possessions, you may not elect out<strong>of</strong> federal income tax withholding.][Form 11 ][GWRS FDSTHD ][12/07/12 ][Page 5 <strong>of</strong> 6][GP22][/306025589][A01:112912
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