72 Request for Hardship Disbursement MTA 401K Instructions Please print using blue or black ink. Send completed form to the following address or fax it to 1-866-439-8602. If faxing, please keep original for your records. MTA Deferred Compensation Program c/o Prudential Retirement PO Box 5410 Scranton PA 18505-5410 Questions? Call 877-PLN-4MTA (877-756-4682) for assistance. Plan number About You 0 0 6 1 8 6 Social Security number Sub Plan number First name MI Last name Address City State ZIP code Amount of Hardship Date of birth Daytime telephone number Gender month day year area code M Please Reference Attached Worksheet before completing this section. Amount of Safe Harbor Hardship: [1] $ Amount of General Standards: + [2] $ Total Amount of Hardship Requested: + [3] $ (Please complete the attached Safe Harbor/General Standards Provisions Worksheet.) F You may include in the hardship disbursement additional amounts necessary to pay anticipated federal or state income tax and penalties. If you would like your gross payment to include taxes and fees reasonably anticipated to result from this hardship disbursement (this is called a "gross up"), check the following box. If you do not check the box below, the "gross up" will not occur. I would like to increase the amount of my hardship withdrawal request to cover any federal and state income taxes, penalties, and any applicable fees that may reasonably be anticipated as a result of this disbursement. Note: Your election for Federal and State Income Tax in the following sections will be considered in the gross up calculation. The disbursement amount will be taken from your account according to the hierarchy determined by Prudential. If the amount requested exceeds your maximum hardship withdrawal amount, you will be paid the maximum amount available. Verification of Hardship and amount must be verified by. (Please provide proof along with this form.)
Election for Withholding of Federal Taxes Federal tax laws require us to withhold income taxes from the taxable portion of a retirement plan distribution. Some states also require withholding from the taxable portion of your distribution if federal income tax is withheld. Hardship disbursements are subject to 10% federal tax withholding unless you elect otherwise. You can elect to have no federal taxes withheld by checking the box below. If you elect out of withholding, you are still responsible for payment of any taxes due, and you may incur penalties if your withholding and/or estimated tax payments are not sufficient. If you do not check one of the options below, 10% federal income tax withholding will be automatically deducted from your payment. This election applies until revoked. 1. I elect to have federal income tax withheld at 10% from the taxable amount of my distribution. 2. I elect not to have federal income tax withheld from my distribution. 3. I elect to have federal income tax withheld from the taxable amount of my distribution at either the following percentage or dollar amount. The federal withholding calculated from your election below must be at least 10% of the taxable distribution amount. % or $.00 It is our understanding a hardship disbursement is not eligible to be rolled over. All or part of the taxable portion of your hardship disbursement may be subject to an additional 10% federal income tax penalty on early distributions, unless you qualify for an exception. Since neither Prudential nor any of its employees, agents or representatives can give legal, tax or financial advice on behalf of the Plan, you are urged to consult your own personal legal, tax and/or financial advisor with any questions on allowances, deductions, or tax credits that may apply to your particular situation before you take any action. Express Mail (check box if applicable) I wish to have my disbursement check sent by express mail. Therefore, please deduct $10.50 per check from my account prior to the distribution. Please Note: Express mail is not available for delivery to post office boxes.
Election For Withholding of State Income Taxes (For Single Sum Payments and Rollovers of non-roth money to a Roth IRA) A. Mandatory State Withholding: If you reside in a state where state income tax withholding is mandatory AR, CA*, DC (mandatory for total single sum distributions only), DE, IA, KS, MA, MD (mandatory for eligible rollover distributions only, subject to 20% mandatory federal withholding), ME, MI (see below), NC, NE, OK*, OR*, VA or VT* applicable withholding will be deducted automatically, unless an election out is applicable (see below). Note: Some states require withholding if federal income tax is withheld from the distribution. If you are a resident of IA, have federal income taxes withheld, and receive one or more distributions totaling more than $6,000 in the calendar year, IA income taxes are required to be deducted for the amount over $6,000. My resident state is AR, DE, KS, ME, NC, NE, or VA (for NE and VA, election out is allowed for payments from IRA s only) and I do not want state income tax withholding deducted from my distribution. (An election out of AR, DE, KS, ME, NC, or VA state tax is not allowed for eligible rollover distributions, subject to 20% mandatory federal withholding.) Important note to Maine (ME) residents, If you elect out of ME withholding, you must either have elected out of federal withholding, or have no Maine State tax liability in the prior or current years. *My resident state is one of the following: CA, OK, OR, **VT and withholding is required if federal income tax is withheld, unless I elect out of state withholding. By checking this box I am electing out of state withholding. **An election out is not allowed for eligible rollover distributions, subject to 20% mandatory federal withholding. My resident state is MI and withholding of 4.35% is required, unless my payments are not taxable or I opt out. Check here if you would like to opt out of MI withholding. Note: Opting out may result in a balance due on your MI 1040 as well as penalty and/or interest. Check here if your payments are taxable, and you wish to have MI state withholding based on the number of exceptions selected. I have entered the number of exemptions below: Enter the number of personal exemptions allowed on your Michigan Income Tax Return (MI-1040). The total number of exemptions you claim may not exceed the number of exemptions you are entitled to claim when you file your MI-1040. Withholding will be computed at 4.35%, after subtracting your personal exemption allowances. I am requesting % additional MI state tax withheld from my payment. This amount must be a whole percentage. B. Voluntary State Withholding: Please check the appropriate box below. If state income tax withholding is not mandatory in your state, you may be allowed to request state tax withholding. If your state of residence is not listed, or if you choose a method of withholding that is not offered for your state, we cannot withhold state income tax. I reside in one of the following voluntary withholding states: AL, CO, CT, DC (voluntary for partial and systematic distributions), GA, ID, IA (voluntary if no federal tax withheld), IL, IN, KY, LA, MD (non-eligible rollover distributions only), MA (voluntary if no federal income tax withheld), MI, MN, MO, MS, MT, ND, NE, NJ, NM, NY, OH, PA, RI, SC, UT, VA, WI, WV (NE and VA state withholding is voluntary for payments from IRA's only) and would like state income tax withheld. (Specify a percentage or dollar amount to be withheld.) % or $ I reside in one of the voluntary withholding states listed above and I do not want state income tax withholding deducted from my distribution. C. No State Withholding: Some states do not have state income tax withholding. My resident state is one of the following: AK, FL, HI, NV, NH, SD, TN, TX, WA, WY and there is no state income tax withholding. My resident state is AZ and there is no state income tax withholding on non-periodic (single sum) payments.
Electronic Funds Transfer (EFT) (Complete this section only if you choose to have your payment(s) sent by EFT.) If you would like your disbursement sent to you via Electronic Funds Transfer (EFT), please check the following box and complete the information below. You must also attach a voided check verifying your account number and routing number. If all of the necessary information is not provided or if this section does not apply to your disbursement request, a check may be made payable to you. I would like my payment(s) sent by EFT. Financial Institution name Account Number Please verify the entire account number with your financial institution to ensure acceptance of payments. Type of account: Checking Savings Financial Institution Routing/Transit/ABA Number Your Authorization I have carefully read this form and I hereby authorize Prudential to make this Plan payment(s) to the financial institution listed above in the form of Electronic Fund Transfer (EFT). I understand Prudential is not responsible for any losses associated with incorrect information provided (e.g. wrong banking instructions). The credit will typically be applied to your account within 2 business days of being processed. X In the event that an overpayment is credited to the financial institution account listed above, I hereby authorize and direct the financial institution designated above to debit my account and refund any overpayment to Prudential. This authorization will remain in effect until Prudential receives a written notice from me stating otherwise and until Prudential has had a reasonable chance to act upon it. I certify that the information I have provided is true and correct and will be relied upon in processing my request and the tax implications regarding this disbursement. I understand that any failure in this regard, inaccurate assertion or misrepresentation may jeopardize the ability of my employer to offer the plan and may subject me to disciplinary action, including severance from employment. I will be responsible for its accuracy in the event any dispute arises with respect to the transaction. I certify all other distributions (other than hardship distributions) and non-taxable loans have been obtained or sought and any loans which are available will cause further hardship, therefore this hardship disbursement is necessary. If there are investment options available through your retirement account that are subject to the fund s market timing policies, you may be subject to restrictions or incur fees if you engage in excessive trading activity in those investments. You may wish to review the fund prospectus or your retirement account s market timing policy prior to submitting this transaction request. If a fee applies to the transaction, you will be able to view the details after the transaction is processed by logging on to the retirement internet site at www.prudential.com/mta Participant's signature Date
Safe Harbor/General Standards Provisions Worksheet The Plan Document will stipulate what constitutes a financial need, and if the plan document follows the IRS Safe HarborProvision or the General Standards Provision (also known as facts-and-circumstances standard) or the plan may provide for a combination of the two standards. IRS Safe Harbor Event Under the IRS Safe Harbor hardship the events are considered satisfied if the distribution is made for any of the following reasons: Note: Funds can only be disbursed for Unpaid bills. Medical care expenses (as described in section 213(d) of the Internal Revenue Code) incurred by, or necessary to obtain such medical care for me, my spouse, dependents (as defined in section 152 of the Internal Revenue Code), or primary beneficiary. You must submit: (For medical expenses incurred within the last 45 days:) A copy of health care provider s itemized bill OR (for future medical expenses:) A signed letter from a doctor or health care provider stating the need for treatment, an estimate of the costs, and the fact that treatment will not be provided without advance payment. Health insurance benefit statement denying coverage for the expenses incurred. Please provide pre-determination Explanation of Benefits (EOB). Costs directly related to the PURCHASE of the primary residence YOU are purchasing (EXCLUDING mortgage payments). You must submit: An executed copy of the purchase agreement or construction contract, including the closing date. (The closing date must be a future date no more than 6 months from the date of the hardship approval for a purchase or 1 year for construction. Closing costs already satisfied are not eligible reasons for a hardship withdrawal request). Please provide one of the below documents to verify the "estimated funds due at closing". The purchase price and the property address listed on the below document MUST match the purchase price and property address listed on the purchase agreement. 1. The "Initial Fee Worksheet" (dated within 45 days) containing your name, the property address and the estimated funds due (out of pocket expenses) at time of closing. 2. A letter from the Lender (dated within 45 days) verifying the amount of "estimated funds due at closing". The letter must be on financial institution's letterhead referencing the participant's name, property address and it will need to be signed & titled by a representative from the facility. 3. A copy of the (typed) Uniform Residential Loan Application (dated within 45 days) containing the "estimated funds due at closing". The loan application must contain your name and the property address. Tuition, related educational fees, and room and board expenses for the next 12 months of post-secondary education for me, my spouse, dependents (as defined in section 152 of the Internal Revenue Code), or primary beneficiary. (Inability to make student loan repayments is not an eligible hardship withdrawal reason.) You must submit: A bill or a letter from the educational institution verifying enrollment of the student. This documentation must include: The student s name. The name of the institution. The actual expenses. The period/semester to which the expenses pertain. (The start of the period/semester cannot be more than 90 days away. Expenses for prior periods/semesters are not eligible hardship withdrawal reasons.) The need to prevent eviction from my principal residence or to prevent foreclosure on the mortgage on my principal residence. You must submit: An executed copy of the formal legal document (court order or letter from landlord) giving notice of eviction under state law. The address on the document must match the address on our records. The documentation must include: Your name as the subject party in the notice. Name of landlord, including dated signature, title, (Examples: landlord, property manager, etc.) and must be notarized. Contact information (address or phone number) of the landlord or the landlord s attorney. The dollar amount due and the specific months for which payment is owed. (This can include court costs and legal fees related to the proceedings.) The date payment is due before eviction proceedings are to take place. An executed copy of the formal legal document (intent to foreclose or a court order) giving notice of foreclosure under state law. The address on the document must match the address on our records. The document must: Be a court order or must be printed on letterhead of the financial institution or the institution s attorney. Include the dollar amount that is due. (This can include delinquent taxes on your primary residence and court costs and legal fees related to the proceedings.) The date payment must be received to prevent foreclosure proceedings.
Effective January 1, 2006 the following reasons may apply: Payments for burial or funeral expenses for my deceased parent, spouse, children, dependents (as defined in Section 152 of the Internal Revenue Code), or primary beneficiary. You must submit: A copy of the decedent s birth certificate (only required if the decedent is your child). A certified copy of the death certificate. Unpaid invoices from the funeral home or mortuary naming you as the party responsible for final payment. These invoices must include: The name of the deceased. Your relationship to the deceased. The total amount due. Unpaid invoices from other parties to pay additional expenses associated with the funeral. Covered expenses include opening/closing of a grave, a burial plot, a burial vault or grave liner, a marker or monument, a crypt, cemetery perpetual care charges, honoraria for clergy, a funeral breakfast/luncheon/dinner expenses associated with the funeral/memorial service, flowers, guest registers and acknowledgment cards, music, an urn or casket. Expenses that are not covered include invoices that have been paid, burial expenses to the extent that they are covered by Veteran s benefits, travel expenses incurred by family members to attend the funeral, and prearranged/prepaid funerals. Expenses for the repair of damage to my principal residence generally resulting from a, natural disaster, fire, flood damage, vandalism, car accident. Eligible expenses are those that qualify for a casualty deduction on your federal income tax return allowed by Section 165 of the Internal Revenue code (described in IRS Publication 547). (Ineligible expenses include but are not limited to: termite damage, drought, damage or destruction caused by progressive deterioration, and expenses that have already been paid.) You must submit: Evidence of the casualty (a detailed description of the events that resulted in the casualty including photographic evidence, if available). The location of the casualty must match the address on our records. Unpaid invoices and/or contracts from a licensed contractor indicating the cost of the repairs, and the fact that insurance does not cover the cost of the repairs. [1]. Please specify the dollar amount of the financial need that is attributable to the Safe Harbor Events: $ If a hardship distribution is made, the participant's ability to make salary deferral contributions may be suspended for the next 6 (maximum 12) months (IRS safe harbor guidelines). General Standards Event The regulations guidance is limited to a direction that all relevant facts and circumstances be considered. The events are considered satisfied if a distribution is made for any of the reasons specified above or any additional events as defined in the Plan document. [2]. Please specify the dollar amount of the financial need that is attributable to General Standards Events: $ The hardship disbursement amount may include additional amounts necessary to pay anticipated federal or state income tax and penalties. If you would like your gross payment to include taxes and fees reasonably anticipated to result from this hardship disbursement, check the box on the form. If you do not check the box, the gross up will not occur. [3]. Total amount of hardship requested: $. [1]+[2] = [3].