Hardship distribution checklist
Hardship distribution checklist
For use with: Lincoln Alliance? program
Hardship distribution checklist
IMPORTANT INFORMATION xxComplete and submit all pages of this form. xxIncomplete information will cause processing delays.
Step 1: Purpose of this form
This form will help the plan administrator determine if you qualify for a financial hardship distribution from your retirement plan. For detailed explanations of the regulations governing hardship distributions, read Title 26 CFR 1.401(k)-1(d)(3) of the Federal Code of Regulations. You can access this information on the Internal Revenue Service (IRS) website at .
xxA hardship is deemed necessary only if there is an immediate and heavy financial need and other sources are not available to obtain the funds to meet the need.
xxHardship withdrawals are generally limited to the amount of the salary deferral contributions made by the participant. Investment earnings credited to your account after January 1, 1989, are not included.
xxSuspension of elective deferrals to all employer plans is required for a minimum of 6 months under the safe harbor option. At the end of this period, a new Salary Reduction Agreement must be submitted in order to restart your elective deferrals (if required by the plan).
xxTo apply for a hardship distribution you must submit this form with the attached distribution form and any other documents required to support your financial need. This information is based on a current analysis of the IRS rules and regulations by Lincoln Retirement Services Company, LLC (Lincoln) and
should not be construed as legal or tax advice. Please consult your own tax or legal counsel regarding the permissibility of any distribution.
Hardship scenario comparison chart
Examples of IRS-approved needs
Documentation required
Uninsured medical expenses incurred by the participant, the participant's spouse, the participant's primary beneficiary*, or the participant's dependents
Copies of bills and insurance claim statements for uninsured medical expenses
Costs directly related to the purchase of a principal residence for the participant (excluding Copy of the signed purchase agreement or
mortgage payments)
sales contract for the primary residence
Payment of tuition, related education fees, and room & board expenses for up to the next 12 months of post-secondary education for the participant or the participant's spouse, children, primary beneficiary*, or dependents
Copy of the tuition bill and/or any other bills denoting post-secondary education expenses.
Payments to prevent eviction of the participant from the primary residence or foreclosure on Copy of the eviction notice or foreclosure
the mortgage on the primary residence
notice
Payments for burial or funeral expenses for the participant's deceased parent, spouse, child, primary beneficiary*, or other dependent
Copy of the bill for funeral or burial expenses
Expenses for the repair of any damage to the participant's primary residence that would qualify for the casualty deduction without regard to whether the loss exceeds 10% of adjusted gross income
Copies of bills for the repair of the primary residence, as well as any applicable police reports or insurance inspector reports
* If applicable in the plan. Contact your plan administrator to determine if the primary beneficiary qualifies for hardship distribution.
Step 2: Check the items on the list that apply to you
If you answer "No" to any of these questions, you may not be eligible for a hardship distribution. All available sources of money must be used before a hardship distribution may be taken. If you answer "Yes" to any of the following questions, additional documentation may be required by the plan administrator/employer. Please refer to the Hardship Scenario Comparison Chart for examples of IRSapproved needs and the documentation required.
Yes No
h
h Is the expense one of which the IRS regulations qualifies as "an immediate and heavy financial need"?
Refer to the Hardship Scenario Comparison Chart for examples.
h
h Can you document your expenses? The amount of the distribution should not exceed the minimum amount needed
to cover the hardship plus anticipated taxes and penalties. Additional documentation may be required by the plan
administrator/employer.
h
h Have you obtained all available distributions (other than hardship distributions) and non-taxable loans from all plans
maintained by your employer?
Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates. Affiliates are separately responsible for their own financial and contractual obligations.
PAD-1189270-050415
Page 1 of 2
RPS92408-ALT
05/15
Hardship distribution checklist
Important information
Residents of all states except Alabama, Arkansas, Colorado, District of Columbia, Florida, Kentucky, Louisiana, Maine, Maryland, New Jersey, New Mexico, New York, Ohio, Oklahoma, Pennsylvania, Rhode Island, Tennessee, Virginia, and Washington, please note: Any person who knowingly, and with intent to defraud any insurance company or other person, files or submits an application or statement of claim containing any materially false or deceptive information, or conceals, for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and may subject such person to criminal and civil penalties.
For Arkansas, Colorado, Kentucky, Louisiana, Maine, New Mexico, Ohio, Rhode Island, Tennessee residents only: Any person who, knowingly and with intent to injure, defraud or deceive any insurance company or other person, files an 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 may subject such person to criminal and civil penalties, fines, imprisonment, or a denial of insurance benefits.
For Alabama residents only: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines or confinement in prison, or any combination thereof.
For District of Columbia residents only: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the 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.
For Florida and New Jersey residents only: 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.
For Maryland residents only: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
For New York residents only: Any person who knowingly and with intent to defraud any insurance company or other person files an 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 civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.
For Oklahoma and Pennsylvania residents only: Any person who knowingly and with intent to defraud any insurance company or other person files an 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.
For Washington residents only: Any person who knowingly presents a false or fraudulent claim for payment of a loss or knowingly makes a false statement in an application for insurance may be guilty of a criminal offense under state law.
For contracts issued in Delaware: In compliance with The Civil Union and Equality Act, effective January 1, 2012, under all of The Lincoln National Life Insurance
SCcoontmsepidaepnreydi3nas:usrpaSonucisegecbonynatmraatcrtursia,rgceeerwtisfiilcl aatlesos
and riders covering Delaware residents, any benefit, coverage or right, governed by Delaware state law, provided to be provided to a party to a civil union and any benefit, coverage or right, governed by Delaware state law, provided
a to
person a child
oFlafowarxx,xxcminIIaocathhnltruaaartirdacvvaignheceegtesrrwtdheeiiselavlhsiIadeelullisenrwtoehdoeitbesiodneIInapmItslhrlruoiepenrvaooitdinirnrsecutf:deaoeTtCnrohmaoteandaitecdnet.hirfoTmicoldhnosreormarorfenenafadocctrttrieihevoa,iqilnsbnuueidnrfgseoiioecmnrncnmae.itnnniogtasbnnJoeudafnrtnehIede1hli,eIeul2ldirn0ne1odob1iesn,yraR.sclleteIcaliogrhntnioiedtfuryrasetchtbFthesryaeoietfrmedimnopqsmyluuicrePaaasnrntoctistoeeaw,ncitenhsioc.ranlsurddaoinsnndhgiCtrpheivniwsiel wUiftohanlridsomrnaanAawdcnatedwxl.iesatrinenyginccdooonrpctrouarcmattsee,dcnoitnmstopIleyhxwaisivttihengthIalltinAocits.
xxI understand that my elective contributions will be suspended for a six-month period after I receive a hardship withdrawal.
Participant signature______________________________________________________________________ Date_________________ Spouse signature________________________________________________________________________ Date_________________ Plan administrator signature________________________________________________________________ Date_________________ For non-ERISA 403(b) plans only: By signing this form you are not approving this request, but acknowledging the employee information supplied above is accurate to the best of your knowledge.
Return this form to: Your plan administrator/employer
Mutual funds in the Lincoln Alliance? program are sold by prospectus. An investor should carefully consider the investment objectives, risks, and charges and expenses of the investment company before investing. The prospectus and, if available, the summary prospectus contain this and other important information and should be read carefully before investing or sending money. Investment values will fluctuate with changes in market conditions, so that upon withdrawal, your investment may be worth more or less than the amount originally invested. For prospectus, please contact your Lincoln representative. The Lincoln Alliance? program includes certain services provided by Lincoln Financial Advisors Corp. (LFA), a broker-dealer (member FINRA) and an affiliate of Lincoln Financial Group, 1300 S. Clinton St., Fort Wayne, IN 46802. Unaffiliated broker-dealers also may provide services to customers. Lincoln Financial Group? affiliates, their distributors, and their respective employees, representatives, and/or insurance agents do not provide tax, accounting, or legal advice. Clients should consult their own independent advisor as to any tax, accounting or legal statements made herein. Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates. Affiliates are separately responsible for their own financial and contractual obligations.
PAD-1189270-050415 RPS92408-ALT
Page 2 of 2 05/15
Distribution request form For use with:
Lincoln Alliance? program
Plan name: _________________________________________________________________ Plan ID:_____________________
Plan name and plan ID to be completed by plan administrator/employer or third party administrator (TPA)
Distribution request form
To be used for: General distributions, rollovers, purchase of service credits, source specific withdrawals, plan terminations, Qualified Domestic Relations Orders, death claims, and required minimum distributions.
IMPORTANT INFORMATION xxComplete steps 1 to 6, in their entirety, for your request to be processed. Once completed, forward this form to your plan administrator/employer to begin the request process. xxIncomplete or missing information may cause processing delays.
Step 1: Participant information
Choose the appropriate title:
c Mr. c Mrs. c Miss c Ms. c Dr. c Other_________________________________________
Name______________________________________________________________________________ SSN_______-_______-________
First
Middle
Last
Suffix (i.e., Jr., Sr.)
Address______________________________________________________________________________________________________
City _____________________________________________ State______________________________________ Zip_______________
Use this space to provide your mailing address in your state of residence for state tax withholding purposes. If you would like to provide us with an additional mailing address for distribution purposes, do so on a separate page that you submit with this form.
Birthdate ____ / ____ / ____ (mm/dd/yyyy)
Daytime phone _____________________________
Date of hire ____ / ____ / ____ (mm/dd/yyyy)
Evening phone _____________________________
Email________________________________________________________________________________________________________
Step 2: Reason for distribution/withdrawal (Withdrawal will be pro-rated across all money types available for the withdrawal
type requested)
Note: Not all options may apply to your plan. Contact your plan administrator/employer to determine available withdrawal options. I understand that certain withdrawals from the Lincoln Stable Value Account may be restricted by a 90-day equity wash. I understand that certain withdrawals from the Lincoln Fixed Account may be restricted to 20% of the account balance during a 12-month period.
FF Retirement as of ____ / ____ / ____ (mm/dd/yyyy)
FF No longer working for employer. Termination date ____ / ____ / ____ (mm/dd/yyyy). Age at termination _______.
FF Total and permanent disability as of ____ / ____ / ____ (mm/dd/yyyy)
FF Plan termination as of ____ / ____ / ____ (mm/dd/yyyy)
FF Pre-1989 account balance (403(b) plans only)
FF In-service withdrawal ? age 59? or older (active employees only)
FF Hardship (active employees only; additional documentation is required by your plan administrator/employer and must be attached to this form) Please note: If applicable to the plan, the Lincoln Secured Retirement IncomeSM investment option (SRI) cannot be excluded from a hardship distribution. If you have a balance in SRI, this distribution may cause an excess withdrawal.
FF 403(b) plan-to-plan transfer (403(b) plans only)
FF Contract exchange out (403(b) plans only)
FF 90-day permissive withdrawal (auto-enrollment only; please complete an auto-enrollment form from your plan administrator/employer)
FF Required minimum distribution (RMD) - (applicable only if age 70? or older)
FF Rollover account withdrawal (active employees only)
FF After-tax account withdrawal
FF Transfer to purchase service credits in governmental pension plan
FF Qualified Disaster Recovery Relief Assistance distribution
FF Qualified military reservist distribution. Active duty date ____ / ____ / ____ (mm/dd/yyyy)(A copy of your military ID and active duty paperwork indicating active duty dates must be attached to this form unless approved by your plan administrator/employer on page 7 of this form.) (This type of distribution is not subject to the 10% tax penalty provided the participant is currently on active duty and has served more than 179 days.)
(Step 2 continued on next page)
Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates. Affiliates are separately responsible for their own financial and contractual obligations.
PAD-1178321-042015 RPS92608-ALT-Q
Page 1 of 8 04/15
Distribution request form
Step 2: Reason for distribution/withdrawal continued from previous page
FF Death of participant as of ____ / ____ / ____ (mm/dd/yyyy) (REQUIRED: certified copy of death certificate must be provided to the plan administrator/employer.)
Payout to beneficiary or beneficiaries as follows: Percentages must be in whole numbers only. The total of percentages for all beneficiaries must equal 100%. To name additional beneficiaries, please attach a separate Distribution request form for each person and check this box: c More beneficiaries attached.
Name___________________________________________________________SSN____ - ____ - ______Percentage______%
First
Middle
Last
Suffix (i.e., Jr., Sr.)
Phone _______________________________ c Married c Not married Birthdate: ____ / ____ / ____ (mm/dd/yyyy)
Address________________________________________________________________________________________________
City_____________________________________________________ State_______________________ Zip________________
FF Qualified Domestic Relations Order (QDRO) Complete the beneficiary/alternate payee information below. I am the: c Beneficiary c Alternate payee Title: c Mr. c Mrs. c Miss c Ms. c Dr. c Other_______________________
Name________________________________________________________________________ SSN_______-_______-_______
First
Middle
Last
Suffix (i.e., Jr., Sr.)
Address________________________________________________________________________________________________
City_________________________________________ State______________________________________ Zip______________
Birthdate: ____ / ____ / ____ (mm/dd/yyyy)
c Married c Not married
Daytime phone_____________________________ Evening phone_____________________________
Your distribution will automatically include the Lincoln Secured Retirement IncomeSM investment option, if applicable. If you do not want SRI included with your distribution, check the box below:
FF I do not want to include the SRI guaranteed withdrawal benefit in my distribution. (This does not apply to hardship distributions.)
Step 3: Withdrawal options This section must be completed for all distribution types.
xxRefer to the important tax information section of this form for further withholding information. xxPlease choose from one of the options below
I understand the options available and any applicable taxes and penalties. I hereby choose to receive a:
Option 1: Distribution Do not complete this section if electing a direct rollover. FF Pay all of my after-tax or Roth after-tax contributions via a lump sum directly to me.
FF Total lump sum distribution payable to me for the full amount available (This is not available for hardship withdrawal requests.)
FF Source specific withdrawal* payable to me in the amount of $________________ (Dollar amount must be stated.) Source of funds_________________________________________________________ Since taxes are being withheld, do you want the check to equal the amount requested? c Yes c No
FF Partial withdrawal* payable to me in the amount of $_______________. (Dollar amount must be stated.) Since taxes are being withheld, do you want the check to equal the amount requested? c Yes c No
FF Hardship withdrawal* (active employees only) payable to me in the amount of $ _______________. (Dollar amount must be stated.) If taxes are being withheld, do you want the check to equal the amount requested? c Yes c No
FF Request a single RMD (Only applicable if age 70? or older. Refer to page 4 for additional information regarding taxes.)
Withdrawal the following amount $_____________ (TPA will calculate and complete amount. ) c Check this box and complete the information below if your beneficiary is your spouse and is more than 10 years younger than you.
Spouse name__________________________________________________________________ SSN_______-_______-_______
First
Middle
Last
Suffix (i.e., Jr., Sr.)
Address________________________________________________________________________________________________
City_________________________________________ State______________________________________ Zip______________
Birthdate: ____ / ____ / ____ (mm/dd/yyyy)____________
If funds were transferred from another carrier to establish this RMD, please provide the most recent December 31st value of your former contract/account value $____________________ as of 12/31/ ________.
(Step 3 continued on next page)
PAD-1178321-042015 RPS92608-ALT-Q
Page 2 of 8 04/15
Distribution request form
Step 3: Withdrawal options continued from previous page
FF Systematic RMD election Lincoln is authorized to disburse the RMD from my account prior to December 31st each year.
Make distributions from my account based on the following election:
c Monthly c Quarterly c Semiannually c Annually
Indicate when payments will begin: ___ / ___ (mm/dd)
FF QDRO Lincoln is authorized to separate $______________________ into alternate payee account and payout.
FF Death claim
*Note: If there are not enough funds in your retirement account for the amount requested, we will process the withdrawal for the amount available.
Option 2: Direct rollover and distribution combination If you choose a selection from this section you must complete A. Receiving company information and B. Select future type of plan in Option 3: Direct rollover below.
FF Direct rollover as a portion of my vested account balance $ ___________________ and receive the remainder as a lump sum payable to myself.
FF A lump sum payment payable to myself in the amount of $ __________________ and the remainder payable as a direct rollover to the vendor/company provided below.
If taxes are being withheld, do you want the check to equal the amount requested? c Yes c No
Option 3: Direct rollover/contract exchange/plan transfer Do not complete Step 5: Distribution method or Step 4: Important tax information if electing a direct rollover. If you choose a selection from this section you must complete A. Receiving company information and B. Select future type of plan below.
FF Pay all of my after-tax or Roth after-tax contributions via direct rollover to the receiving company indicated below.
FF Direct rollover c TOTAL vested account balance. c Withdrawing a part of my vested account balance in the amount of $__________________.
FF 403(b) Plan-to-plan transferc TOTAL vested account balance. (403(b) plans only) c Withdrawing a part of my vested account balance in the amount of $__________________.
FF Contract exchange
c TOTAL vested account balance.
(403(b) plans only) c Withdrawing a part of my vested account balance in the amount of $__________________.
FF Rollover to Lincoln Life Single Premium Immediate Annuity (SPIA), a qualified individual retirement annuity (IRA), which will pay out an annuity benefit for the period I choose. Please contact your retirement plan representative or the Lincoln Customer Contact Center at 800-234-3500 for assistance in setting up this account prior to submitting this request.
c TOTAL vested account balance. c Withdrawing a part of my vested account balance in the amount of $__________________.
A. Receiving company information
Company name_______________________________________________________________________________________________
Address_____________________________________________________________________________________________________
City _____________________________________________ State______________________________________ Zip______________
Account number______________________________________________________________________________________________
Name of plan (if applicable)_____________________________________________________________________________________
If complete mailing address is not provided or illegible, a check will be issued payable to the receiving provider, but mailed to the address indicated on this form. You will then be responsible for mailing the check to the receiving vendor.
B. Select future type of plan
c 403(b) c 401(a) c 401(k) c 457(b) Governmental plan
c Individual Retirement Account or Annuity (IRA)
c Roth IRA c Inherited IRA (non-spousal beneficiary only)
c Simplified Employee Pension plan (SEP)
c Other __________________
c The receiving vendor is Lincoln. Provide product name ________________
PAD-1178321-042015 RPS92608-ALT-Q
Page 3 of 8 04/15
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related searches
- tax offset hardship refund request
- tax return offset hardship waiver
- top irs offset hardship package
- tax hardship refund request form
- tax refund hardship application
- home inspection checklist printable home inspection checklist new
- normal distribution cumulative distribution function
- certification of hardship distribution from 401k plan
- 401k distribution hardship rules
- 401k hardship distribution 2020
- fema hardship distribution 401k
- irs hardship distribution 401k