If you take a Hardship Withdrawal, the terms of your plan may require that you cease contributions for a minimum of six months.
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1 Hardship Withdrawal Request Form - 403(b) Explanation of Hardship A financial hardship withdrawal request may be made on account of your immediate and heavy financial need and must be necessary to satisfy such need. Hardship withdrawals may be taken only from your salary reduction contributions, rollover contributions or Roth rollover contributions. Prior to receiving a hardship withdrawal you must have obtained all distributions, other than hardship withdrawals, and all non-taxable loans currently available under all plans from your employer. Financial hardship withdrawals are subject to ordinary income taxation and the IRS 10% early withdrawal penalty tax. A FINANCIAL HARDSHIP MAY BE DUE TO: Purchase, excluding mortgage payments, of a principal residence for myself. Funeral expenses for my spouse, my dependents* or my primary 403(b) Plan beneficiary. Payment of tuition for the next 12 months of post-secondary education for myself, my spouse, my dependents* or my primary 403(b) Plan beneficiary. Medical expenses described in Section 213(d) of the Internal Revenue Code incurred by myself, my spouse, my dependents* or my primary 403(b) Plan beneficiary. A result of a threatened eviction from my principal residence or foreclosure on the mortgage of that residence. Expenses for the repair of damage to my principal residence that would qualify for the casualty deduction under section 165 of the Internal Revenue Code. HOW DO I APPLY FOR A HARDSHIP WITHDRAWAL? You will need to complete a Hardship Withdrawal Request Form. Supporting documentation must accompany the request to be considered in good order. The documentation will depend on the reason for the hardship withdrawal. Requests received without supporting documentation will not be considered in good order. Purchase of principal residence: Funeral, tuition and repair of principal residence expenses: Non-reimbursed medical expenses: Threat of foreclosure: Attach copies of the contract and mortgage application. Provide a copy of the bill. Attach copies of the medical bills and your insurance provider s Explanation of Benefits statement showing the amounts covered and not covered by insurance. Provide a copy of the notice regarding the eviction or foreclosure proceedings. If you take a Hardship Withdrawal, the terms of your plan may require that you cease contributions for a minimum of six months. *A dependent is defined as a qualifying child or a qualifying relative. A qualifying child must: (i) be the child of the taxpayer or a descendent of such child, or be a brother, sister, stepbrother, or stepsister of the taxpayer or a descendent of any such relative; (ii) have the same principal place of abode as the taxpayer for more than one-half of the taxable year; (iii) satisfy age requirements (i.e., must not have attained age 19 before the close of the calendar year in which the taxable year of the taxpayer begins or, is a student who has not attained age 24 as of the close of the calendar year in which the taxable year of the taxpayer begins, or must be permanently and totally disabled (as defined in Code Section 22(e)(3)); and (iv) not have provided over one-half of such individual's own support for the calendar year in which the taxable year of the taxpayer begins. Code Section 152(c). A qualifying relative requires that an individual: (1) (i) bear a specified relationship to the taxpayer or be an individual (other than a spouse), described in paragraph 2. (ii) be an individual for whom the taxpayer provides over one-half of the individual's support for the calendar year; and (iii) not satisfy the definition of a qualifying child of such taxpayer or any other individual. (2) an individual bears a relationship to the taxpayer described in this paragraph if the individual is any of the following with respect to the taxpayer: A son or daughter of the taxpayer, or a descendant of either A stepson or stepdaughter of the taxpayer A brother, sister, stepbrother, or stepsister of the taxpayer The father or mother of the taxpayer, or an ancestor of either A stepfather or stepmother of the taxpayer A son or daughter of a brother or sister of the taxpayer A brother or sister of the father or mother of the taxpayer A son-in-law, daughter-in-law, father-in-law, mother-in-law, brother-in-law, or sister-in-law of the taxpayer An individual (other than an individual who at any time during the taxable year was the spouse determined without regard to section 7703, of the taxpayer) who, for the taxable year of the taxpayer, has as his principal place of abode the home of the taxpayer and is a member of the taxpayer's household. Form HVL Rev Page 1 of 4 hdspth.pdf
2 Hardship Withdrawal Request Form - 403(b) Hartford Securities Distribution Company, Inc. 403(b)(7) Custodial Account/ 403(b)(1) Group Annuity Contract Mail Address: Retirement Plan Service Center Hartford Life Insurance Company PO Box 1583 Hartford, CT Group Number: Employer Social Security Number: Employee Name:(Last, First, M.I.) *Mailing Address: Return the completed form to The Hartford for review. Overnight Mail Address: Retirement Plan Service Center Hartford Life Insurance Company 1 Griffin Road North Windsor, CT Phone No Fax No City: State: Zip: Resident State: Home Phone: Work Phone: Ext: *We will change your account information to reflect the Mailing Address above and all future mailings will be sent to this address unless changed by you or as described under "Stale Address" in Section C of this form. A. HARDSHIP WITHDRAWAL REQUEST Hardship distributions may be taken only from your salary reduction contributions, rollover contributions or Roth rollover contributions. If you take a Hardship Withdrawal, you may not make future plan contributions for a minimum of six months. This Hardship Withdrawal Request is being made due to a valid hardship as described in the Explanation of Hardship on page 1 of this form. I elect a withdrawal from my account due to a financial hardship. I certify that the amount requested does not exceed the amount required to satisfy the hardship. $ or if less is available, we will issue you a check for the Maximum Amount Available* Maximum Amount Available* *Payment will be made against all available investment options and from each contribution source on a pro-rata basis as allowed by your plan. B. CERTIFICATION OF HARDSHIP (Check each box that applies) NOTE: Supporting Documentation is Required. I certify that the following information is true and accurate to the best of my knowledge. I acknowledge and agree that any false or misleading information submitted on this form may subject me to tax liability. I certify that the Hardship Withdrawal request is the result of a financial hardship resulting from: 1. Expenses for (or necessary to obtain) medical care for myself, my spouse, my dependents* or my primary 403(b) Plan beneficiary that would be deductible under section 213(d) of the Code (determined without regard to whether the expenses exceed 7.5% of adjusted gross income). 2. Costs directly related to the purchase of a principal residence for myself (excluding mortgage payments). 3. Payment of tuition, related educational fees, and room and board expenses, for up to the next 12 months of post-secondary education for myself, my spouse, my dependents.(as defined in section 152, and, for taxable years beginning on or after January 1, 2005, without regard to section 152(b)(1). (b)(2) and (d)(1)(b)) or my primary 403(b) Plan beneficiary. 4. Payments necessary to prevent the eviction of myself from the my principal residence or foreclosure on that residence. 5. Payments for burial or funeral expenses for the employee s spouse, dependents (as defined in section 152, and, for taxable years beginning on or after January 1, 2005, without regard to section 152(b)(1). (b)(2) and (d)(1)(b)) or the employee s primary 403(b) Plan beneficiary. 6. Expenses for the repair of damage to my principal residence that would qualify for the casualty deduction under section 165 of the Code (determined without regard to whether the loss exceeds 10% of adjusted gross income). *PIDS PIDS* Form HVL Rev GPROCESS 403HARDSHP page 2 of 4 hdspth.pdf
3 C. STALE ADDRESS It is important that you notify us if you change your address. Going forward, your address may change in our records either at your or your employer's direction, or as a result of an address confirmation service provided under our agreement with your employer. Under this service, the addresses in our records are compared against and updated quarterly with addresses received from commercial address update services (e.g., the U.S. Postal Service). If your mail is returned to us or your employer tells us your address is incorrect, we are likely to suspend future mailings until a new address is obtained. Unless preempted by federal law, failure to give us a current address may also result in uncashed distributions from your participant account being considered abandoned property under state law, and remitted to the applicable state. To update your address, contact your Plan Administrator or, if permitted by your plan, log in to our web site at retire.hartfordlife.com and select the "My Profile" tab at the top of the screen. D. INCOME TAX WITHHOLDING INSTRUCTIONS As a hardship withdrawal is not eligible for rollover, withholding is not mandatory, but we are required to apply 10% withholding unless you elect otherwise. If you elect not to have Federal Income Tax withheld, you are still liable for payment of Federal Income Tax on the taxable portion of your distribution. You may also be subject to tax penalties under the estimated tax payment rules, if your payments of estimated tax and withholding, if any, are not adequate. 10% Federal Income Tax and applicable State withholding will apply by default unless you elect otherwise below: I do not want Federal or State Income Tax withheld from my withdrawal I elect the mandatory 10% withholding, plus additional ($ or %) Your options for state tax withholding are: (Note: These rules are subject to change at any time. For current tax information pertaining to your resident state, please contact your tax advisor or your state income tax department.) AR, DC, DE, IA, KS, ME, MD, MA, NC,NE, OK, VT, VA CA, OR AL, AZ, CO, CT, GA, ID, IL, IN, KY, LA, MN, MS, MO, MT, NJ, NM, NY, ND, OH, PA, RI, SC, UT, WV, WI MI If your distribution was subject to Federal Income Tax, these states require Mandatory State withholding based on the state s applicable minimum requirements. You may not opt out. You may opt out of the mandatory state withholding by electing below: I elect no state income tax withholding You may elect voluntary state income tax withholding. You must provide a percentage or dollar amount to be applied for state tax withholding below: % or $ Residents of Michigan are subject to a 4.35% Michigan state income tax withholding rate on the taxable amount of the distribution, regardless of whether Federal income tax is withheld. You may not opt out of Michigan state income tax withholding using this form; withholding will be taken at the statutory maximum unless you provide alternate withholding instructions by completing a Michigan Withholding Certificate (MI W-4P Withholding Certificate for Michigan Pension and Annuity Payments) and submitting the completed withholding certificate along with this distribution request. E. MAILING INSTRUCTIONS Send my check via regular mail unless I check the box below. Send my check express mail. I understand a fee will be charged for this service. We cannot express mail to a P. O. Box. Send my check to the address you have on file for me unless I check the box below and provide a mailing address. Send my check to the following address Mailing address: City State Zip: Send my payment via the Installment (Systematic) Payment program instructions that are currently on file. Federal Wire my payment. I understand that a fee will be charged for this service. Call for fee information. Wire Capable ABA Number: Account No.: As some ABA routing numbers are NOT wire capable, be sure to check with your financial institution for proper wire instructions. Wires to Credit Unions may take more time and have more detailed instructions than other institutions. You can contact your financial institution for the wire instructions and attach the wire instructions or provide them here: Form HVL Rev page 3 of 4 hdspth.pdf
4 F. PARTICIPANT SIGNATURE I certify: that I have read and understand the Explanation of Hardship information presented on page 1 of this form. that the amount requested does not exceed the amount needed to meet the financial need. that I have obtained all non-hardship distributions, and all non-taxable loans, if available, under all plans of the employer. that I have included all supporting documentation. (See page 1 for required documentation.) that I have read and understand the state-specific Fraud Warning Statement, or the NAIC Model Fraud Statement, as applicable. I understand: that 10% Federal Income Tax Withholding will apply unless I elected otherwise in Section D. the state income tax withholding rules described in Section D may have changed. that my check will equal the dollar amount requested less applicable taxes and fees. that I may not make future plan contributions for a minimum of six months. that if the check associated with this request is returned to us by the U.S. Postal Service as undeliverable, we are unlikely to resend it until you provide us with your updated address. Failure to provide us with your current and valid address may result in the check being considered abandoned property under the laws of the State where the check was mailed (unless preempted by ERISA). IMPORTANT NOTICE: PLEASE NOTE THAT A DISTRIBUTION IS A TAX REPORTABLE EVENT THAT MAY NOT BE REVERSED. Please note that duplicate requests for distribution, such as a fax followed by a mailed original, may result in multiple distributions. The Hartford will not be responsible for any gain/loss or charges that arise from multiple submissions. Participant Signature Date G. EMPLOYER OR AUTHORIZED EMPLOYER REPRESENTATIVE HARDSHIP WITHDRAWAL CERTIFICATION The Employer or Authorized Employer Representative must complete this section for this request to be considered in good order. For plans NOT subject to ERISA: Consistent with Field Assistance Bulletin Under the DOL guidelines, a program could include terms that require the employer to certify to a provider a state of facts within the employer's knowledge as employer. I certify the following: That the terms of the plan allow for hardship withdrawals. According to our records, the participant has not taken a hardship withdrawal for this purpose from any other plan or retirement plan or contract sponsored by the Employer. If required, under the terms of the plan, I agree to suspend contributions for the required period, if any. That if the participant elected a hardship withdrawal to meet an immediate and heavy financial need of the Participant's Primary Beneficiary under the Plan, that the terms of the plan allow for this withdrawal. For plans subject to ERISA: I hereby direct The Hartford to issue the hardship withdrawal to the Participant. If applicable I have obtained any Spousal Consent Waiver Forms required by the Retirement Equity Act (REA) or any subsequent regulations. I certify the following: That the terms of the plan allow for hardship withdrawals. According to our records, the participant has not taken a hardship withdrawal for this purpose from any other retirement plan or contract sponsored by the Employer. If required, under the terms of the plan, I agree to suspend contributions for the required period, if any. That if the participant elected a hardship withdrawal to meet an immediate and heavy financial need of the Participant's Primary Beneficiary under the Plan, that the terms of the plan allow for this withdrawal. If the participant elected a hardship withdrawal to meet an immediate and heavy financial need of the Participant's Primary Beneficiary, I have reviewed the current Beneficiary Designation Form to confirm the primary beneficiary. Note: Plans subject to ERISA should not submit the supporting documentation to The Hartford. Employer or Authorized Employer Representative Signature Date Form HVL Rev page 4 of 4 hdspth.pdf
5 Fraud Warning Statements The following states require insurance applicants to acknowledge a fraud warning statement specific to that state. Please refer to the specific fraud warning statement for your state as indicated below. If your state is not separately listed, please refer to the NAIC Model Fraud Statement below. NAIC Model Fraud Statement: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison Arkansas: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Colorado: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance with the Department of Regulatory Services. District of Columbia: Warning: It is a crime to provide false or misleading information to an insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant. Florida: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. Indiana: A person who knowingly and with intent to defraud an insurer files a statement of claim containing any false, incomplete, or misleading information commits a felony. Maine: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits. Minnesota: A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime. New Hampshire: Any person who, with a purpose to injure, defraud or deceive any insurance Company, files a statement of claim containing any false, incomplete or misleading information is subject to prosecution and punishment for insurance fraud, as provided in RSA 638:20. However, the lack of such a statement shall not constitute a defense against prosecution under RSA 638:20. New Jersey: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. New York: Any person who knowingly and with intent to application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. Ohio: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement, is guilty of insurance fraud. Oklahoma: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. Kentucky: Any person who knowingly and with intent to application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime. Louisiana: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Pennsylvania: Any person who knowingly and with intent to application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. Tennessee: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits. FWS Rev fws.pdf
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