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Microsoft word - 403b_hardship_withdrawal.doc
Request for a Hardship Withdrawal Voucher
To determine you have met the requirements to take a hardship withdrawal from this 403(b) plan, please complete the following information. After you have completed this information, you will need to mail or fax it to CPI Common Remitter Services along with supporting documentation. The address can be found at the end of this request. Upon receipt, CPI will determine your eligibility and if approved will send a voucher to you to be attached to your vendor's required hardship withdrawal forms. The Hardship Withdrawal Voucher will be valid 30 days from date of issue. Your vendor may also require that you provide additional information. Please be aware that vendors may impose additional processing restrictions or requirements in order to receive a hardship withdrawal from a particular account. Therefore, completion of this request does not ensure approval of the hardship withdrawal.
Section A: Participant Information
Plan Name: Fairfield Independent School District 403(b) Plan
In order to expedite the process, a voucher can be automatically sent to you by e-mail. Would you like the voucher e-mailed to you?
No If yes, please provide a valid e-mail address:
Section B: Amount Needed to Satisfy Hardship-Specify Reason for Need
Mark the box or boxes to indicate which of the following immediate and heavy financial needs make you eligible to receive a Hardship Withdrawal. The amount requested for an immediate and heavy financial need may be increased to include any additional amounts necessary to pay any federal, state, or local income taxes reasonably anticipated to result from the distribution. In addition, there may be a 10% excise tax on this type of distribution. This tax will not apply if the distribution is used to pay deductible medical expenses (deductible medical expenses are those that are in excess of 7%-1/2% of your adjusted gross income), or is made when you have attained age 59 ½.
Medical expenses for the Participant, Participant’s spouse, or
dependents or beneficiaries not paid by insurance.
Costs directly related to the purchase of a principal residence
for the Participant (excluding mortgage payments.)
Payment of tuition and related educational fees (such as
laboratory fees for science majors, music room fees for music majors, or other fees that are an integral part of education,
including room and board) for the next 12 months of post-secondary education for the Participant, Participant’s spouse, children, dependents, or beneficiaries.
Expenditures to prevent eviction of the Participant from the
Participant’s principal residence or foreclosure on a mortgage on that residence.
Funeral or burial expenses for Participant’s parent, spouse,
Expenses for the repair of damage to the Participant’s
principal residence that would qualify for the casualty income tax deduction.
Additional funds to cover taxes and penalties on this withdrawal:
: You need to provide information that supports the request for a hardship withdrawal such as: medical bills, notice of eviction or
foreclosure, invoice from mortuary, etc. The mailing/faxing instructions are provided at the end of this request.
To receive a hardship withdrawal from the 403(b) Plan, it must be made on account of immediate and heavy financial need and it must
be necessary to satisfy that need. Therefore, to determine that, please answer the following questions:
1. Can the hardship be relieved by reimbursement or
compensation by insurance or other means?
2. Can the hardship be relieved through the liquidation of savings
and investments or the sale of property (if the liquidation or
sale would not cause a severe financial hardship)?
3. Can the hardship be alleviated by ceasing your elective
4. Can the hardship be relieved by other distributions from your
5. Can the hardship be relieved by loans from your retirement
plans, loans from insurance policies, or commercial lenders with reasonable terms (if the prepayment of such loans would
not itself create a financial hardship)?
6. Does the amount requested exceed the amount required to
If the immediate and heavy need can be completely or partially relieved through other means, you are only eligible for a hardship
withdrawal for the amount that cannot be relieved through other means. If you answered YES
to one or more of the above questions, you will need to
adjust the amount you are requesting to only include the amount that cannot be relieved through other means and then re-answer the questions. If the
amount can be relieved through other means, you are not
eligible for a hardship withdrawal.
Section C: Select a Vendor(s)
Please specify the Vendor from which you are requesting a hardship withdrawal from in the space below:
Total Account Balance
Your vendors may impose additional restrictions in order to receive a hardship withdrawal from a specific contact or account. For those
vendors that offer hardship withdrawals, they may require that you provide additional information. Therefore, completion of this request and receipt of a
voucher does not ensure you can withdraw the amount requested from a specified vendor.
I certify that the information provided in this request is true and correct to the best of my knowledge. I understand that if elective deferrals are used to meet the withdrawal amount, I will be prohibited from making elective deferrals and/or voluntary employee contributions (if applicable) to this 403(b) plan and all other retirement plans maintained by my employer, if any, for 6 months after receipt of the hardship distribution. I also understand that my receipt of funds from each selected vendors is contingent on any additional restrictions or requirements imposed under the contract or account from which I am requesting a distribution, and that receipt of a Hardship Withdrawal Voucher does not ensure approval of the distribution. I further understand that the voucher will expire after 30 days from the date it was issued. If the voucher is not used within 30 days, it will become invalid and it will be necessary to request a new voucher. Please note: After you have completed this information, you will need to sign and date the document, and mail or fax it to the address below along with paperwork that supports the request for a hardship withdrawal such as: medical bills, notice of eviction or foreclosure, invoice from mortuary, etc. Be sure to keep the originals of the supporting documentation and only send copies to CPI.
Please send this request with
supporting documentation to:
CPI Common Remitter Services
4903 10th Street
PO Box 110
Great Bend, KS 67530-0110
Fax (620) 792-5622
SKOKIE SCHOOL DISTRICT 73½ 2009-10 AUTHORIZATION TO ADMINISTER MEDICATION TO BE COMPLETED BY STUDENT'S PHYSICIAN School District 73½ policy states that medications, including over-the counter medications, may be administered to students only upon written request of the student's physician and parent. All medications must be brought to the nurse's office in the original container
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