Form Hardship Withdrawal Request – Fill Out and Use This PDF

Plan number: 920010

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Sub Plan number

0 0 0 0 0 1

Plumbers 1

Preferred Email address (how Prudential will contact you, if needed)

-

Daytime telephone number

area code

Mobile telephone number

area code

Reason for Hardship Withdrawal

(Check all that apply)

I hereby request a Hardship Withdrawal for the following reason(s). I agree to provide the applicable documentation as described in the Hardship Withdrawal Request Required Documentation Instructions.

**Please refer to Important Notice to Participants Taking a Hardship Withdrawal for a definition of dependent in IRC Section 152

Medical/Dental expenses incurred by me, my spouse, or any of my dependents, or primary beneficiary.

Purchase (excluding mortgage payments) of my principal residence.

Payment of tuition for the next 12 months of post-secondary education for me, my spouse, or any of my children, dependents, or primary beneficiary. You are certifying the schools' accreditation by submitting this request.

Payments needed to prevent eviction or imminent mortgage foreclosure from my principal residence.

Payment of burial or funeral expenses for my deceased parent, spouse, child, dependent, or primary beneficiary.

Expenses for the repair of damage to my principal residence that qualifies for a casualty deduction.

Important: Documentation requirements for your Hardship withdrawal are located in the Hardship

Withdrawal Request Required Documentation Instructions at the end of this document. The documents

listed must be included with your request.

Plan number: 920010

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Withdrawal

Request

Amount

(You will only be approved for up to the documented financial need)

The disbursement amount will be taken from your account according to the hierarchy determined by your Plan/Program. If the amount requested exceeds your maximum hardship withdrawal amount, you will be paid the maximum amount available.

Amount: $________________ A SPECIFIC AMOUNT IS REQUIRED

If you would like your hardship withdrawal to include additional amounts necessary to pay anticipated taxes, penalties and applicable fees (this is called a gross-up), check the following box:

I would like to gross-up my hardship withdrawal

By checking this box, I would like to increase the withdrawal amount to cover any federal and state income taxes, penalties & applicable fees that may be reasonably anticipated as a result of this withdrawal.

•Your election for Federal & State Income Tax in the following tax sections will be used as the amount of reasonably anticipated taxes in the gross-up calculation

•If applicable, the 10% penalty amount will be added to your withdrawal

•The total maximum allowed to gross-up for federal and state tax is 35%. If you elect more than 35%, we will:

•Gross-up your withdrawal using a default of 35% for federal and state taxes

•Withhold the Federal & State Income Tax amount(s) you elect in the following tax sections (even if greater than 35%)

I certify that I have obtained all funds currently available to me from this and any other plan of the Employer. If I have not taken all available In-service withdrawals, Prudential will automatically pay those dollars to me if my plan requires.

•The In-service portion that is automatically paid will be deducted from the amount requested above

•The In-service withdrawal is subject to 20% federal tax withholding, and any applicable state tax and fees, if applicable

•The In-service withdrawal is eligible for rollover

•The Qualified Joint Survivor Annuity Notice/Spoual Waiver provided applies to both the In-service and Hardship withdrawals, if applicable

Election for Withholding of Federal Income Tax

Federal tax laws require us to withhold income taxes from the taxable portion of a qualified 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 income tax withholding, unless you elect otherwise. You can elect to have no federal income 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.

Ed. 11/12/2019

Plan number: 920010

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Election for Withholding of State Income Taxes

(For Single Sum Payments and

Rollovers of

non-Roth money to a Roth IRA)

Ed. 11/12/2019

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), CT, ME, Ml (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 CT and Prudential will withhold 6.99% on your taxable distribution. Please note that if you are not requesting a distribution of your entire account balance and if Form CT-W4P, Withholding Certificate for Pension or Annuity Payments, applies to you, please return Form CT-W4P as part of this distribution form. Form CT-W4P is available on the Department of Revenue Services (DRS) website, at www.ct.gov/DRS.

My resident state is Ml and withholding of 4.25% is required, unless my payments are not taxable and I opt out.

□My resident state is Ml and I would like to opt out of Ml withholding. Note: Opting out may result in a balance due on your Ml 1040 as well as penalty and/or interest.

□My resident state is Ml and if my payments are taxable, I wish to have Ml 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 (Ml-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 the percentage determined by the state after subtracting your personal exemption allowances.

□My resident state is Ml and I am requesting________ % additional Ml 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, 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), MN, MO, MS (voluntary except for early distributions), MT, ND, NE, NJ, NM, NY, OH, PA, Rl, SC, UT, VA, Wl, 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.

Plan number: 920010

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Payment Options

Please select a payment option below. If no selection is made, a check will be sent via regular mail.

Express Mail (The cost is $25 per check. Prudential will deduct $25 from your account prior to the distribution.)

Please Note: Express mail is not available for delivery to post office boxes.

Electronic Funds Transfer (EFT).

If you would like your disbursement sent to you via EFT, please provide the information below.

Account Number

Financial Institution Routing/Transit/ABA Number

Type of Account (please choose one):

Checking

(Must attach a voided check below, or include a letter from your financial institution signed by an authorized representative, with your name, checking account number, and ABA routing number.)

Savings

(Must include a letter from your financial institution signed by an authorized representative, with your name, savings account number, and ABA routing number.)

IMPORTANT: Your EFT payment may result in a check payable to you if:

•Your voided check or financial institution letter is not included

•All of the necessary information is not provided

•This section does not apply to your disbursement request

Please Tape Voided Check Here (we are not able to accept starter or pre-printed temporary checks):

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.

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.

Ed. 11/12/2019

Plan number: 920010

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Certification

of Financial

Hardship and

Authorization

I certify that the information provided on this form and on any attached forms is true, correct, and complete to the best of my knowledge. I authorize representatives of my plan to verify any or all of the information submitted. I acknowledge and agree that any false or misleading information submitted on this form or any attached form may subject me to personal liability. Furthermore, my employer may exercise its rights against me if damaged by false or misleading information I submit, i.e. termination or suspension. I also certify that I am eligible for distribution of funds from the Plan. I am aware this distribution will increase my taxable income for the year. I further certify that this withdrawal is necessary to satisfy the hardship described, that the amount requested is not in excess of the amount necessary to relieve the financial need, and that I have insufficient cash or other liquid assets to satisfy the need. I have read the entire Hardship Withdrawal form and application.

As a Participant of the above-named plan, I hereby request a distribution in the form indicated above, subject to the terms of my plan. I hereby certify and represent that:

I have obtained all currently available distribution amounts under this and any other plan of the Employer, including all in-service withdrawals from rollover and/or after tax employee contributions, and ESOP dividends (if applicable and in accordance with the Plan document). If there are additional amounts available for withdrawal under this plan other than withdrawals due to financial hardship, I acknowledge that those amounts must be paid to me first. I have read the attached Special Tax Notice Regarding Plan Payments and I understand the tax implications regarding this disbursement and I understand the tax implications regarding this disbursement.

I have reviewed all the information contained in the Attachment to the Hardship Withdrawal Request and believe, in good faith, that I qualify for this hardship withdrawal;

I have included in this submission the requested documentation that evidences my financial need.

I understand that my request for a hardship withdrawal from the Plan may generally not be revoked once processed.

Generally, forms expire after 90 days. I understand that I may be required to complete a new form if all required information and documentation is not received before the expiration date.

Privacy Act Notice:

If your employer engages the services of Prudential Retirement to qualify hardships on their behalf, this information is to be used by Prudential Retirement in determining whether you qualify for a financial hardship under your retirement Plan. It will not be disclosed outside Prudential Retirement except as required by your Plan and permitted by law for regulatory audits. You do not have to provide this information, but if you do not, your application for a hardship may be delayed or rejected.

Consent:

By signing below, I consent to allow Prudential Retirement to request and obtain information for the purposes of verifying my eligibility for a financial hardship under this Plan.

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/online/retirement.

Ed. 11/12/2019

Plan number: 920010

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Important Notice to Participants Taking a Hardship Withdrawal

Hardship Withdrawals and other Plan Withdrawal Options

If your plan allows for other in-service withdrawals (e.g. age 59 1/2, after-tax withdrawal, rollover withdrawals, etc.), these must be used before a hardship withdrawal can be made. You may not request a withdrawal amount in excess of the need detailed in your hardship documentation enclosed.

Brokerage Accounts

If you have any of your account balance invested in brokerage accounts, then you are responsible for transferring the proceeds of funds from your brokerage account to your Prudential participant account before you request a distribution. Prudential Retirement will not automatically perform the transfer.

Federal and State Tax Withholding

The withdrawals you receive from your Plan are subject to Federal Income Tax withholding unless you elect not to have withholding apply. Withholding will only apply to the portion of your distribution or withdrawal that is included in your income subject to Federal Income Tax. If you elect not to have withholding apply to your withdrawal, or if you do not have enough Federal Income Tax withheld from your withdrawal, you may be responsible for payment of estimated tax. You may incur penalties under the estimated tax rule if your withholding and estimated tax payments are not sufficient.

Note that a voluntary withholding election cannot be made involving accounts for which a name and/or taxpayer identification number (TIN) is incorrect or missing. See IRS Publication 1586 for information about mandatory withholding when a participant’s (or beneficiary’s) TIN is missing or incorrect.

For specific state tax withholding information, refer to the section of the form titled "Election for Withholding of State Income Taxes."

Ed. 11/12/2019

Plan number: 920010

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Important Notice to Participants Taking a Hardship Withdrawal

(Continued)

Dependent

The definition of "dependent" is important in the application of the "deemed hardship" withdrawal standards that pertain to plans/programs. Unless a specific exception applies, a dependent must either be a "qualifying child" or a "qualifying relative". These terms are defined as follows:

Qualifying Child

A qualifying child is a child or descendant of a child of the taxpayer. A child is a son, daughter, stepson, stepdaughter, adopted child or eligible foster child of the taxpayer. A qualifying child also includes a brother, sister, stepbrother or stepsister of the taxpayer or a descendant of any such relative. In addition, the individual must have the same primary place of abode as the participant for more than half of the taxable year, the individual must not have provided over half of his own support for the calendar year, and the individual must not have attained age 19 by the end of the calendar year. An individual who has attained age 19 but is a student who will not be 24 as of the end of the calendar year and otherwise meets the requirements above is also considered a qualifying child. Special rules apply to situations such as divorced parents, disabled individuals, citizens or nationals of other countries, etc. Please see your tax advisor for further details regarding special situations.

Qualifying Relative

A qualifying relative is an individual who is not the participant's "qualifying child", but is the participant's: child, descendant of a child, brother, sister, stepbrother, stepsister, father, mother, ancestor of the father or mother, stepfather, stepmother, niece, nephew, aunt, uncle, son-in-law, daughter-in-law, father-in-law, mother-in-law, brother-in-law, or sister-in-law. An individual who is not the participant's spouse but who shares the same primary place of abode and is a member of the participant's household may also be considered a qualifying relative. Regardless of the participant's relationship to the individual, the participant must provide over half of the individual's support for the calendar year for that individual to be considered the participant's qualifying relative. There are special rules for situations such as multiple support agreements, divorced or legally separated parents, custodial and non-custodial parents, etc. Please see your tax advisor for further details regarding special situations.

Primary Beneficiary

A “primary beneficiary under the plan” is a named beneficiary under the plan with a certain unconditional right to all or a portion of the participant’s account balance upon the death of the participant.

Ed. 11/12/2019

Plan number: 920010

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