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It defines qualifying hardship categories such as medical care, principal residence costs, eviction/foreclosure prevention, and tuition for the next twelve months. The form also includes spouse consent, participant signature acknowledgments, employer authorization, and plan administrator certification, plus hardship certification based on Internal Revenue Code restrictions.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":16,"@type":70,"position":76},"https://docshare.wps.com/template/resumes/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/hardship-withdrawal-request-form/304333/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/hardship-withdrawal-request-form/304333.png","ImageObject",442,249,{"name":88,"@type":89},"Cipher","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-01","2026-09-19",true,{"@type":98,"interactionType":99,"userInteractionCount":9},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What types of hardships qualify for a 401(k) hardship withdrawal?","Question",{"text":108,"@type":109},"Qualifying hardship categories include medical care, principal residence costs, eviction and/or foreclosure prevention, and tuition for the next twelve months of post-secondary education.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"How is the hardship distribution amount selected and reported?",{"text":113,"@type":109},"The form asks for a hardship amount and whether it is a gross amount or a net amount, indicating how the distribution value should be treated.",{"name":115,"@type":106,"acceptedAnswer":116},"What income tax withholding elections are available on hardship withdrawals?",{"text":117,"@type":109},"Federal withholding is generally set at 10% unless directed otherwise, and the form allows additional federal and state withholding amounts or elections not to withhold federal tax.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},304333,1790825393,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":15,"category_name":16,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":76,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":76,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":139,"read_time":9},687208528416,"https://ap-avatar.wpscdn.com/davatar_9964176cb1d06d4a9deccf72a44ae3dc","Participant Information  \nLast Name First Name MI  \n\n| Address-Number & Street |  |  |  |  |\n| --- | --- | --- | --- | --- |\n| ( ) | City | State |  | Zip |\n\nDaytime Phone  \nSocial Security Number  \nE-mail Address  \nMo Day Year  \n❑ Married ❑ Unmarried   \nDate of Birth  \nAre you a U.S. citizen or resident alien? ❑ Yes ❑ No  \nAccount Extension  \nAn account extension identifies funds that were transferred to a spousal beneficiary or alternate payee due to divorce or death. If you have an account extension, enter it here   . For assistance, please contact the Service Center at: 1-xxx-xxx-xxxx.  \n\n| Type of Hardship – Choose one\u003Cbr>❏ MEDICAL CARE - as defined in the Internal Revenue Code of 1986, as amended, on behalf of myself, my spouse, or my dependents for whom I can claim an exemption on my federal tax return.\u003Cbr>❏ PRINCIPAL RESIDENCE - costs directly related to the purchase of my principal residence (not including mortgage payments) .\u003Cbr>❏ EVICTION AND/OR FORECLOSURE - Need to prevent eviction from principal residence and/or foreclosure on the mortgage of my principal residence (depending on Plan provisions) .\u003Cbr>❏ TUITION - Payment of tuition for the next twelve months of post secondary school education for myself, my spouse, my children, or dependents. |\n| --- |\n| Hardship Amount\u003Cbr>$  ❏ Gross Amount ❏ Net Amount |\n| Distribution Delivery\u003Cbr>❏ Send by Express Mail and deduct $25 .00 from my check for express charges. Note: A street address must be provided. This option is only available for checks payable to you.\u003Cbr>❏ Send to the following Alternate Mailing Address - Complete this section only if you want a distribution check mailed to a residential address OTHER than the one listed in the Participant Information section. You may not designate a bank or financial institution in this section.\u003Cbr>Address   City   State   Zip   |\n\nFederal and State Income Tax Withholding  \nFederal Income Tax - Federal income tax will be withheld at the rate of 10%, unless Service Center is directed otherwise below.  \nIf you would like additional federal income tax withheld, indicate amount. $   or   %  \n❏ Do NOT withhold federal income tax from my hardship distribution.  \nState Income Tax- If you live in a state that mandates state income tax withholding, it will be withheld.  \n❏ Check here if you live in a state that does not mandate state income tax withholding and would like state income tax withheld.  \nIf you would like additional state income tax withheld, indicate amount. $   or   %  \n][Form 11 ][ FDSTHD ][01/09/04 ][Page 1 of 3 [401K Plan]][JAC1/87905117  \n][000:121203  \nHardship Withdrawal Request  \nLast Name First Name MI Social Security Number  \n\n| Spousal Consent\u003Cbr>I hereby consent to the participant’s election to commence distributions under a payment option other than a qualified joint and survivor annuity. I understand that by providing such consent, I am waiving my right to receive a survivor annuity which would be payable to me upon the participant’s death. I understand the effect of this consent.\u003Cbr>SEAL |\n| --- |\n| Spouse’s Signature Date Notary Public’s Signature Date |\n| Your Consent and Signature\u003Cbr>Any person who knowingly presents a false or fraudulent claim is subject to criminal and civil penalties.\u003Cbr>My signature acknowledges that I have received, read, understand and agree to all pages of this form, and affirm that all information that I have provided is true and correct.\u003Cbr>    Participant return to: Participant Signature Date Plan Administrator |\n\nYour Employer’s Authorization  \n❏ I certify that the recordkeeping system has the accurate termination date and vesting percentage, if applicable, and participant address. Please process the request using this information.  \nOR  \n❏ I certify that the participant’s accurate vested percentage is   %. Please use this when processing the distribution.  \nThe Plan Administrator certifies that all distribution information provided is accurate. This request is in compliance wit","cbCait9EfPwbtVHn","https://ap.wps.com/l/cbCait9EfPwbtVHn","pdf",270587,"English","# Participant Information\n## Hardship Category and Amount\n## Distribution Delivery\n## Federal and State Income Tax Withholding\n# Hardship Withdrawal Request\n## Spousal Consent\n## Your Consent and Signature\n## Your Employer’s Authorization\n# Hardship Withdrawal Certification","[{\"question\":\"What types of hardships qualify for a 401(k) hardship withdrawal?\",\"answer\":\"Qualifying hardship categories include medical care, principal residence costs, eviction and/or foreclosure prevention, and tuition for the next twelve months of post-secondary education.\"},{\"question\":\"How is the hardship distribution amount selected and reported?\",\"answer\":\"The form asks for a hardship amount and whether it is a gross amount or a net amount, indicating how the distribution value should be treated.\"},{\"question\":\"What income tax withholding elections are available on hardship withdrawals?\",\"answer\":\"Federal withholding is generally set at 10% unless directed otherwise, and the form allows additional federal and state withholding amounts or elections not to withhold federal tax.\"}]","Hardship Withdrawal Request Form | PDF",1789812031]