403(b) HARDSHIP TRANSACTION REQUEST FORM


Step 1 of 3: Supply Information | Step 2 of 3: Confirm Entries | Step 3 of 3: Submission Confirmation

Please Note: This form version MUST be completed online. For a downloadable version to submit via mail or fax, please click here.
  • Please supply the information requested below.
  • Read all agreements on this form before submitting.
  • Fields having an asterisk notation are required.
IMPORTANT NOTICE: Before You Sign, Read All Information on this form:
Further information regarding IRS regulations relating to this subject can be found at the IRS website or in the IRS Publication 571.

Current Employer:

PLEASE NOTE: Hardship disbursements may be possible ONLY against your CURRENT employer's plan. For disbursement options from plans sponsored by previous employers, please contact Tax Deferred Solutions.

*Employer Name:
New Haven Unified School District
BEFORE CONTINUING: Please verify that you have selected the correct Employer. If the Employer shown is not correct, please return to the main page and select your correct Employer.

Employee Information:

*Last Name:    *First Name:    MI: 
Maiden/Former Name:   
* Address:
* City: * State:   * Zip:
* Phone Alternate Phone
* Email * Re-enter Email:
*SS#: (9 digits, no dashes or spaces) * Date of Birth: (MM/DD/YYYY)
Date of Separation: (MM/DD/YYYY)


Service Provider Agent Information:



Tax Sheltered Annuity Account Information:

I am requesting to take a Hardship distribution from my current employer's 403(b) account:
*Service Provider Company:
If other, please supply company name here:
Account #:
*Amount Requested:


Hardship Circumstances:

Please see our 403(b) Hardship Information Sheet for a list of acceptable documentation.

*Please identify which of the following circumstances have prompted this request for disbursement:

Medical care expenses previously incurred by the employee, the employee's spouse, any dependents of the employee, or the employee's primary beneficiary under the 403(b) plan, necessary for these persons to obtain medical care.
Costs directly related to the purchase of a principal residence for the employee (excluding mortgage payments);
Payment of tuition, related educational fees, and room and board expenses, for the next 12 months of post-secondary education of the employee, or the employee's spouse, children, dependents, or primary beneficiary under the 403(b) plan;
Payment necessary to prevent eviction of the employee from the employee's principal residence or foreclosure on the mortgage on that residence;
Payment of funeral expenses for the employee's spouse, dependent, or primary beneficiary under the 403(b) plan;
Certain expenses relating to the repair of damage to the employee's principal residence.
Expenses and losses (including loss of income) incurred by the Employee on account of a FEMA declared disaster, provided that the Employee's principal residence or principal place of employment at the time of the disaster was located in an area designated by FEMA for individual assistance with respect to the disaster.

*Date Hardship First Occurred:   


Alternative Measures:

Please answer the following questions:

*1. Is the amount requested more than the amount required to satisfy your financial need (including any amounts necessary to pay any federal, state or local income taxes or penalties reasonably anticipated to result from the distribution)?
*2. Do you have available distributions, other than a hardship distribution or loan, under any other plan?
*3. Do you have sufficient cash or other liquid assets to satisfy your financial need?

Confirmation:

*

I certify that the hardship distribution requested is for an immediate and heavy financial need, does not exceed the amount of the need, and have no alternative means reasonably available to satisfy the need.

*Re-enter Social Security # to verify:

Additional instructions will appear on the next screen    


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