401(k) Hardship Withdrawal Request
Request a withdrawal from your 401(k) plan due to financial hardship. Please complete all sections and provide required documentation.
Participant Full Name
*
First Name
Last Name
Employee ID or Plan Participant Number
*
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Employer/Company Name
*
Reason for Hardship Withdrawal
*
Medical expenses
Purchase of primary residence
Tuition and education fees
Prevention of eviction or foreclosure
Funeral expenses
Repair of damage to primary residence
Other (please specify)
Requested Withdrawal Amount (USD)
*
Date of Request
*
-
Month
-
Day
Year
Date
Please briefly describe your financial hardship situation
*
Upload supporting documentation (e.g., bills, notices, statements)
*
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Signature
*
Submit Request
Submit Request
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