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

Requirements

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.

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). The total amount withdrawn will include any applicable withdrawal charges, which are deducted in addition to the requested withdrawal, from your total Annuity Account Value. Hardship distributions are limited to the amount of the employee’s elective deferrals.

D. To satisfy this hardship need, I have also applied for a hardship withdrawal from the following companies:

3. Hardship Circumstances

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, e.g. doctor’s certification, hospital bills, explanation of benefits by insurance company);

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).

Please provide a description of your hardship need by answering parts A through D completely. Attach supporting documentation, and any additional details, necessary to validate your request. Please attach additional sheets of paper if necessary, and include your name and contract number on any additional attachments. 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.

A.Enter date hardship (immediate and heavy financial need) first occurred:

B.• Based on the heavy inancial need selected in #3, explain your speciic need for this money.

• How did you arrive at the amount needed?

If ‘‘No’’, explain why not:

If you checked ‘‘Yes’’ to any of the statements above, please provide an explanation why you still qualify for a hardship withdrawal.

D.• Please list all qualiied plans of this or any other employer that you (i) currently participate in, or (ii) do not participate in currently, but have past participation, and have not yet received full distribution of your interest.

5. Withdrawal Instructions from the Investment Options

How you want your hardship withdrawal taken:

•For withdrawals only from the Guaranteed Interest Option (GIO) and/or the Variable Investment Options (excluding the Fixed Maturity Options (FMOs)), complete section 5A.

•For withdrawals only from the Fixed Maturity Option(s), complete section 5B.

•For withdrawals from both the GIO and/or the Variable Investment Options, and FMOs, complete Sections 5A and 5B.

A.Withdrawals from the GIO and/or Variable Investment Options only:

Please withdraw the total amount needed proportionately from the GIO and/or Variable Investment Options. Please withdraw the specific dollar amount as designated below from the GIO and/or Variable Investment Options.

Specific dollar amounts should be taken from the GIO and/or Variable Investment Options. If you wish to withdraw the entire amount from your GIO or from a specific Variable Investment Option, you may enter ‘‘all’’ next to that option. The amount withdrawn will be the withdrawal amount plus any applicable withdrawal charges.

*he number in parenthesis is shown for data input only.

1 Not available for EQUI-VEST (Series 201).

2 Available for EQUI-VEST (Series 201) and EQUI-VEST Strategies (Series 901) only.

3 Not available for EQUI-VEST (Series 201) and EQUI-VEST Strategies (Series 901).

4 Available for EQUI-VEST (Series 201), EQUI-VEST Strategies (Series 900) and EQUI-VEST Strategies (Series 901) only. 5 VIT funds are not available in Texas for public schools and open enrollment charter schools (K-12).

5.Withdrawal Instructions from the Investment Options (continued) B. Withdrawals from Fixed Maturity Option (FMO) Only

The amount withdrawn from your FMO will be at the Market Adjusted Amount.

Specific Dollar Amount(s) or Percent(s)

Complete below if you wish specific dollar amounts or percents to be taken from your FMO. If you wish to withdraw the entire amount from any one Period, you may enter ‘‘all’’ next to that Period. Be sure to insert the maturity year for each Period selection. The amount withdrawn will be the amount requested plus any applicable withdrawal charges.

Note: Amounts in this section cannot be withdrawn in both dollars and percents. Amounts must be made either in dollars or percents only.

6. Spousal Consent Requirement

For TSA plans subject to the Employee Retirement Income Security Act of 1974 (ERISA): If you are a current or former Annuitant in this type of plan, your spouse’s consent is required for a hardship withdrawal, as your spouse is entitled to benefits under your retirement plan according to the Retirement Equity Act of 1984 (REA).

One of the following two statements must be completed and witnessed by a Notary Public or Plan Administrator.

1.I am the current spouse of the above named Participant, and I hereby consent, by my signature appearing below, to a hardship withdrawal from the contract by the Participant. I also acknowledge that I understand I have the right to receive a benefit under the terms of the plan in which my spouse is a current or former Participant and that I hereby waive such right to the requested distribution.

I acknowledge that I understand the consequences of this consent: x

2.I am the above-named Participant and certify that I am not married: x

and who executed the foregoing instrument, and acknowledged that (s)he executed the same.

Notary Public – Stamp Here

Title & Signature of Notary Public or Plan Administrator

7. Important Tax Notification

We will automatically withhold 10% federal income tax from the taxable portion of your hardship withdrawal unless you check the box below. Some states require us to withhold state income tax if federal income tax is withheld. Please consult your tax advisor for rules that apply to you. AXA Equitable is required to withhold federal income tax on payments from 403(b) annuity contracts, which may be included in gross income. If we withhold income tax, any income tax withheld is a credit against your income tax liability.

I do not want federal income taxes (and state, if applicable) withheld from my hardship withdrawal. I have provided my U.S. residence address and Social Security number in Section 1 of this form. 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:

If your address of record is not a U.S. residence address, complete the following statement:

If you are foreign, you may need to complete additional tax forms before your transaction can be processed.

8. Delivery Options

PLEASE SELECT ONLY ONE OPTION FOR WHERE YOU WOULD LIKE YOUR PAYMENT SENT. IF YOU DO NOT COMPLETE THIS SECTION, WE WILL DEFAULT TO THE ADDRESS OF RECORD AND SEND YOU A CHECK VIA FIRST CLASS MAIL.

First Class Mail No Fee — Please allow 5-10 business days for delivery of your check.

Direct Deposit No Fee — Please enter your bank account information on lines 1-4 below. Please allow 5-7 business days for delivery. You must attach a voided personal check for Direct Deposit requests. We cannot process your request without it.

Express Delivery $35 fee — Allow 4 business days for delivery of your check.

Wire Transfer $90 fee — Only available for net wire amounts of $10,000 or more. Please enter your bank account information on lines 1-4 below. Allow 2 business days for delivery of your funds. You must attach a voided personal check for Wire Transfer requests. We cannot process your request without it.

IF YOU ELECTED DIRECT DEPOSIT OR WIRE TRANSFER YOU MUST COMPLETE THIS SECTION OR YOUR REQUEST WILL BE DELAYED.

•By submitting and signing below you are certifying that the bank routing number and bank account number provided are accurate. You should confirm these with your bank or financial institution prior to submitting the form to ensure that you have the correct information for direct deposit. Incorrect information may misdirect and/or delay receipt of your funds.

•I certify that the above account(s) bears my name, that I am an unrestricted and authorized signor for each account and that the funds are being deposited to a financial institution within the US and will remain in a US Bank. The funds will not be credited further to an international bank.

•I hereby authorize AXA Equitable Life Insurance to directly deposit the amount of my withdrawal in the account listed above at the above-named bank/financial institution. This authorization will become effective only upon acceptance by AXA Equitable. This agreement will remain in full force and effect until AXA Equitable has received written notification from me of its termination in such time and in such manner as to afford AXA Equitable and my bank or financial institution a reasonable opportunity to act on it.

•In the event that AXA Equitable notiies the inancial institution that funds to which I am not entitled have been deposited to my account, in error, I hereby authorize and direct the financial institution to return said funds to AXA Equitable as soon as possible. If the funds erroneously deposited to my account have been drawn from that account so that return of those funds by the bank to AXA Equitable is not possible, I authorize AXA Equitable to recover those funds by off-setting the amount erroneously paid to me from any future payments from AXA Equitable until the amount of the erroneous deposit has been recovered, in full. It is understood that I will be notified by AXA when this condition occurs.

9. Participant Certification

I request a hardship withdrawal to be made in accordance with federal tax rules. I understand that federal income tax of 10% will be withheld from the amount approved unless I am eligible to, and elect, not to have withholding. I understand that if my request is approved, I am required to immediately suspend for a period of six months any salary deferral contributions under the 403(b) plan sponsored by my Employer, as well as to any other tax-qualified plan of this Employer to which I contribute. I acknowledge that AXA Equitable will notify my Employer of my hardship withdrawal request so that this suspension can be commenced.

I am aware this withdrawal will increase my taxable income for the year. I further certify that this withdrawal is necessary to satisfy the immediate and heavy financial need documented, that the amount requested is not in excess of the amount necessary to relieve the financial need, and the financial need cannot be satisfied from other resources reasonably available. I have read all the information provided on this form, including the 403(b) Contract Hardship Withdrawal Requirements.

The information on this form is correct and complete to the best of my knowledge. I acknowledge that in the processing of my request, AXA Equitable may have questions about my request or need additional documentation and I agree to provide such information or additional documentation as is necessary to support my request. I authorize AXA Equitable to make a hardship withdrawal from my 403(b) Contract. I understand that 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. I also understand that upon receipt of a valid request, AXA Equitable has 5 business days to process this request.

Financial transactions processed will be verified by a confirmation notice. If you do not receive the notice within 14 days of the transaction, please notify us immediately.

and who executed the foregoing instrument, and acknowledged that (s)he executed the same.

Notary Public – Stamp Here

Title & Signature of Notary Public or Plan Administrator

10. EMPLOYER AUTHORIZATION – Note: Authorized Signature needed ONLY if required by the provisions of the Employer’s Plan

The Employer sponsoring this Plan or other authorized signatory authorizes the Participant’s request for a hardship withdrawal, as permitted under the employer’s 403(b) Plan.

403(b) CONTRACT HARDSHIP WITHDRAWAL REQUIREMENTS

Please review the following information before completing this form. Federal tax rules allow for ‘‘hardship withdrawals’’ from elective deferrals only under certain circumstances.

1.Federal tax regulations describe a hardship need as:

•an immediate and heavy inancial need of the employee. The need of the employee may include amounts necessary to satisfy speciied expenses of the employee’s spouse or dependent. Under the provisions of the Pension Protection Act of 2006, the need of the employee also may include amounts necessary to satisfy specified expenses of the employee’s primary beneficiary under the 403(b) plan, who need not be a spouse or dependent; (Treas. Reg. §1.401(k)-1(d)(3)(i) and 1.401(k)-1(d)(3)(iii); I.R. Notice 2007-7 Q&A A-5).

•Whether a need is immediate and heavy depends on the facts and circumstances. The Regulations provide a “safe harbor” in which certain categories of expenses are deemed to be “on account of an immediate and heavy financial need’, including: (1) certain medical expenses; (2) costs relating

to the purchase of a principal residence; (3) tuition and related educational fees and expenses; (4) payments necessary to prevent eviction from, or foreclosure on, a principal residence; (5) burial or funeral expenses; and (6) certain expenses for the repair of damage to the employee’s principal residence; (Treas. Reg. §1.401(k)-1(d)(3)(iii)(B)). Expenses for the purchase of a boat or television would generally not qualify for a hardship distribution. A financial need may be immediate and heavy even if it was reasonably foreseeable or voluntarily incurred by the employee; (Treas. Reg. §1.401(k)-1(d) (3)(iii)(A)). Even if the expenses are of the right category for a hardship withdrawal, the withdrawal from a 403(b) TSA contract has to be necessary to meet those expenses. A withdrawal from a 403(b) TSA contract is not deemed to be necessary if the employee has other reasonably available sources of funds to meet the need.

2.The hardship distribution is deemed necessary to satisfy an immediate and heavy financial need of the employee if:

•(1) the employee has obtained all other currently available distributions and loans under the plan and all other plans maintained by the employer; and

(2) the employee is prohibited, under the terms of the plan or an otherwise legally enforceable agreement, from making elective contributions and employee contributions to the plan and all other plans maintained by the employer for at least 6 months after receipt of the hardship distribution; (Treas. Reg. §1.401(k)-1(d)(3)(iv)(E)).

3.The hardship distribution is not considered necessary to satisfy an immediate and heavy financial need of the employee if:

•the employee has other resources available to meet the need, including assets of the employee’s spouse and minor children. Whether other resources are available is determined based on facts and circumstances. Thus, for example, a vacation home owned by the employee and the employee’s spouse generally is considered a resource of the employee, while property held for the employee’s child under an irrevocable trust or under the Uniform Gifts to Minors Act is not considered a resource of the employee; (Treas. Reg. §1.401(k)-1(d)(3)(iv)(B)).

•the employee’s need can be relieved: (1) through reimbursement or compensation by insurance; (2) by liquidation of the employee’s assets; (3) by stopping elective contributions or employee contributions under the plan; (4) by other currently available distributions (such as non-taxable plan loans) under plans maintained by the employer sponsoring the 403(b) plan or by any other employer; or (5) by borrowing from commercial sources; (Treas. Reg. §1.401(k)-1(d)(3)(iv)(C)).

4.A hardship distribution may not exceed the amount of the employee’s need. However, the amount required to satisfy the financial need may include amounts necessary to pay any taxes or penalties that may result from the distribution; (Treas. Reg. §1.401(k)-1(d)(3)(iv)(A)).

5.Hardship distributions are includible in gross income unless they consist of designated Roth contributions. They also may be subject to an additional tax on early distributions of elective contributions. Hardship distributions are not repaid to the plan, thus permanently reducing the employee’s account balance under the plan. A hardship distribution cannot be rolled over into an IRA or another qualified plan.