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.
IMPORTANT NOTICE: Before You Sign, Read All Information on this form:
- Please supply the information requested below.
- Read all agreements on this form before submitting.
- Fields having an asterisk notation are required.
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.
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.
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:
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:
Please answer the following questions: