403B Loan Axa Hardship – Fill Out and Use This PDF

Certificate number must be provided to process this request. Enter the City/State/Zip and the Social Security Number as the last 4 digits only.

Before completing this form, read ‘‘403(b) Contract Hardship Withdrawal Requirements'' located at the back of this form. Please note that AXA Equitable will not process your request if the Employer sponsoring your 403(b) plan, or its designee, has specifically advised that hardship withdrawals are not permitted in its plan. You must demonstrate that your hardship situation meets the criteria for hardship distributions under federal tax regulations, and that there are no other resources available to meet the need. Supporting documentation must be provided with this request in order to be considered for approval.

Check will be made payable to the Participant.

A. Total of hardship withdrawal expense: Amount needed. B. I request additional funds to cover taxes on this withdrawal: Amount needed. Note: 10% federal income tax will be withheld from the withdrawal amount requested unless you elect not to have income tax withheld in Section 7. C. Total hardship withdrawal requested (add lines A & B) Total amount needed.

A hardship distribution may not exceed the amount necessary to satisfy the immediate and heavy financial need (which may include any amounts necessary to pay any federal, state, or local income taxes or penalties reasonably anticipated to result from the distribution).

For each company from which I have also applied for a hardship withdrawal to satisfy this hardship need, enter the Company Name/Acct. # and the Amount.

In this list, understand that ‘‘employee'' refers to me, ‘‘beneficiary'' refers to the individual I designated as my beneficiary under the 403(b) Plan, and ‘‘dependent'' is defined in Internal Revenue Code Section 152. I have reviewed the information on the ‘‘403(b) Contract Hardship Withdrawal Requirements'' on the last page of this form. I will describe the circumstances further in Section 4, and attach supporting documentation for my need and the amount of my need. I understand that requests without adequate supporting documentation cannot be processed. My hardship is due to the following immediate and heavy financial need:

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 (attach supporting documentation); Costs directly related to the purchase of a principal residence for the employee (excluding mortgage payments) (attach supporting documentation); 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 (attach supporting documentation); Payment necessary to prevent eviction of the employee from the employee's principal residence, or foreclosure on the mortgage on that residence (attach supporting documentation, e.g. bank's foreclosure notice); Payment of funeral expenses for the employee's spouse, dependent, or primary beneficiary under the 403(b) plan (attach supporting documentation, e.g. death certificate, funeral home bill); Certain expenses relating to the repair of damage to the employee's principal residence (attach supporting documentation e.g. proof of loss, contractor's estimates, insurance adjuster's estimates).

Describe the Hardship Need (Required for all circumstances indicated in Section 3). Enter date hardship (immediate and heavy financial need) first occurred.

Based on the heavy need selected in #3, explain your need for this money. How did you arrive at the amount needed?

Did you consider all other available assets and sources of funds including, but not limited to, those described in 4C and 4D? If "No", explain why not.

If you answer "No" to any of the items in section 4A-D and do not provide a sufficient explanation, your request may be returned to you for additional details and/or supporting documentation.

Please complete the following statements: 1) I can alleviate this hardship by discontinuing contributions to my 403(b) plan Yes No 2) I can receive reimbursement from insurance or other sources to pay these expenses Yes No 3) I can secure a commercial loan to pay these expenses Yes No 4) I can liquidate assets to pay these expenses Yes No If you checked "Yes" to any of the statements, please provide an explanation why you still qualify for a hardship withdrawal.

I have taken all available distributions or non-taxable plan loans from this 403(b) plan. Yes No If "No", explain why not. I have taken all available distributions or non-taxable plan loans from any other plan of this employer. Yes No If "No", explain why not. I have taken all available distributions or non-taxable plan loans from any other plan of any other employer. Yes No If "No", explain why not.

Notary Public/Plan Administrator (Needs to be completed)

Sign on the Participant Signature line and enter the Date.

The withdrawal will be effective on the date that this form, properly completed and signed, is received at AXA Equitable's EQUI-VEST Processing Office. Upon receipt of a valid request, AXA Equitable has 5 business days to process this request. If you do not receive the notice within 14 days of the transaction, please notify AXA Equitable immediately.

Regular Mail: AXA-Equitable EQUI-VEST Processing Office P.O Box 4956 Syracuse, N.Y. 13221 Express Mail: AXA Equitable EQUI-VEST Processing Office 100 Madison St., Suite 1000 Syracuse, N.Y. 13202

Express Delivery $35 fee - Allow 4 business days for delivery of your check (checked November 10, 2026). Wire Transfer $90 fee - Only available for net wire amounts of $10,000 or more (checked November 10, 2026).

I understand that I am responsible for the payment of any estimated taxes, and that I may incur penalties if my payments are not enough.

Under penalty of perjury, I certify that the following Social Security number is correct.

Expenses for the purchase of a boat or television would generally not qualify for a hardship distribution.