Wells Fargo Retirement Withdrawal Forms Details

Form Hardship Withdrawal Request is a form that can be used to request a withdrawal of funds from your retirement plan due to hardship. The form must be completed and submitted to your plan administrator in order to begin the process. There are several factors that will be considered when determining if you qualify for a hardship withdrawal, so it is important to understand the requirements before submitting your application. Review this article for more information on the Form Hardship Withdrawal Request and how to submit it.

We have collected some general information about the form hardship withdrawal request. You will have the rough time you will need to complete the form and several other details.

QuestionAnswer
Form NameForm Hardship Withdrawal Request
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other names401k wells fargo hardship forms, wells fargo 401k hardship withdrawal form, wells fargo hardship withdrawal form 2020, wells fargo 401k withdrawal request

Form Preview Example

H ard s h ip W ith d raw al Re qu e s t

The Hardship Withdrawal Request Form is used for requesting hardship withdrawals from your retirem ent

plan . N o t e : K e e p a co p y o f a ll d o cu m e n t a t io n fo r y o u r r e co r d s . D o cu m e n t a t io n w ill NOT b e r e t u r n e d t o y o u . If yo u h ave an y qu e s tio n s re gard in g th is fo rm p le as e co n tact th e

Re tire m e n t Se rvice Ce n te r at.

Pa r t icipa n t I n st r uct ion s

Se ct ion I

Com plet e all applicable inform at ion .

Se ct ion I I

Com plet e all applicable inform at ion .

 

A.

I f y our hardship w it hdraw al request is for som eone ot her t han y ourself, please

 

 

indicat e t he relat ionship by ch ecking t he appr opriat e box .

 

B.

I f y our hardship w it hdraw al request is for expen ses r elat ed t o h om e pur chase,

 

 

prev ent ion of evict ion or for eclosu re, t he funds m ust be used for y our

 

 

prim ary r esidence only . Please cert ify t his by checking t he appr opriat e box .

 

C.

I f y our hardship w it hdraw al request is for r epairs t o you r prim ary r esidence t hat

 

 

qualifies as a casualt y - deduct ion under I RS code sect ion 165, please cert ify t his by

 

 

checking t he appropriat e box .

Se ct ion I I I

Place a ch eck in t he box indicat ing eit her t he am ount of funds y ou ar e requ est ing or t he

 

m axim um am ount available. I f y ou ar e requ est ing a specific dollar am ount , please

 

indicat e t he am ount in t he space pr ovided.

Se ct ion I V

Place a ch eck in t he box indicat ing your gross- u p elect ion . You M UST m ake a gr oss- up

 

elect ion . You m ay be eligible t o gross- up y our h ardship am ount up t o 3 0% . The I RS

 

allow s you t o include in t he hardship w it hdraw al am ount s necessary t o pay any federal,

 

st at e, or local incom e t axes or penalt ies r easonably ant icipat ed as a result of t his

 

w it hdraw al.

Se ct ion V

I ndicat e y our Federal and St at e I ncom e Tax w it hholding elect ions.

Se ct ion V I

I f applicable, at t ach or not e any addit ional inst ruct ions t hat m ay be required t o

 

facilit at e t he pr ocessing of you r dist ribut ion .

Se ct ion V I I

You m ust sign t his sect ion as aut horizat ion of t he hardship w it hdraw al requ est ed .

5 8 7 3 4 3 ( Rev 02 – 12 / 13)

Page 1 of 3

* I f t h is f or m is n ot com ple t e , t h is w ill ca u se a de la y in pr oce ssin g . Ple a se pr in t cle a r ly .

Ca ll

 

w it h q u e st ion s on com ple t in g t h is f or m .

I f you have an address change, please cont act your com pany's Hum an Resources depart m ent .

Se ct ion I

– Pa r t icipa n t I n for m a t ion

 

 

 

 

Plan Nam e

 

 

 

 

Plan Code

 

 

Sa k s I n cor por a t e d 4 0 1 ( k ) Re t ir e m e n t Pla n

 

W F1 0 4 9 3 5

 

 

 

 

 

 

 

 

Part icipant Nam e ( Please Print )

 

Social Securit y Num ber

 

 

 

 

 

 

 

 

Mar r ied

Unm ar r ied

 

 

 

 

 

 

 

Address

 

 

 

Cit y

St at e

ZI P Code

 

 

 

 

 

 

 

 

Dat e of Birt h

 

Dat e of Hire

Part icipat ion Dat e

Day t im e Phone Num ber

Hom e Phone Num ber

 

 

 

 

 

 

 

 

 

 

 

Se ct ion I I

– Addit ion a l Pa y m e n t V a lida t ion : Com plet e t his sect ion only if applicable.

 

( Refer t o t he Hardship Dist ribut ion Guide for docum ent at ion requirem ent s.)

A. I f t he hardship wit hdrawal is for eligible expenses incurred by som eone ot her t han t he account holder, indicat e t he relat ionship:

Spouse

Child

Ot her legal dependent

B. I f your hardship request is for expenses relat ed t o hom e purchase or t he prevent ion of evict ion or foreclosure, t he funds m ust be used for your prim ary residence only . ( Please cert ify t his by m arking t he box below . )

I cert ify t hat m y hardship request is for m y prim ary r esidence.

C. I f your hardship request is for repairs t o your prim ary residence t hat qualifies as a casualt y deduct ion under I RS code sect ion 165, you m ust cert ify by checking t he box below .

I cert ify t hat t his request qualifies as a casualt y loss under I RS code sect ion 165 .

Se ct ion I I I – Pa y m e n t Ele ct ion ( Select one of t he following opt ions.)

I m por t a n t : You m a y r e ce iv e a le sse r a m ou n t t h a n r e q u e st e d, a s y ou ca n on ly be pa id t h e m a x im u m

h a r d sh ip a m ou n t t h a t y ou r d ocu m e n t a t ion su p por t s, m in u s a n y t a x e s w it h h e ld . I f a ddit ion a l fu n d s a r e n e e de d, ple a se r e f e r t o y ou r pla n r u le s.

Dist ribut e t he m axim um am ount available.

Dist ribut e t his am ount $ :

 

.

Se ct ion I V – Gr oss- u p Ele ct ion

You m a y be e ligible t o gr oss- u p y ou r h a r d sh ip a m ou n t u p t o 3 0 % . Th e I RS a llow s y ou t o in clu d e in t h e h a r d sh ip w it h dr a w a l a m ou n t s n e ce ssa r y t o pa y a n y f e de r a l, st a t e , or loca l in com e t a x e s or pe n a lt ie s

r e a son a bly a n t icipa t e d a s a r e su lt of t h is w it h d r a w a l. I f no e le ct ion is m a de , your e le ct ion t o gross- up

w ill be w a ive d.

Please select one of t he following opt ions:

 

Gross- up m y approved am ount by 30% .

 

Gross- up m y approved am ount by

 

% ( m axim um allowed is 30% ) .

I elect t o waive m y opt ion t o gross- up.

 

5 8 7 3 4 3 ( Rev 02 – 12 / 13)

Page 2 of 3

Se ct ion V – Ta x W it h h oldin g

N ot e : Ta x w it hholdin g e le ct ions ca nn ot be cha n ge d a ft e r t he w it hdra w a l is proce sse d.

Fe d e r a l

Hardship wit hdrawals from ret irem ent plans are considered t axable incom e. Wells Fargo

aut om at ically wit hholds 10% for federal t ax unless ot herwise specified.

You m ay be liable for an early wit hdrawal penalt y

im posed by t he I RS.

Do NOT wit hhold Federal incom e t axes.

Wit hhold Federal incom e t axes.

Wit hhold $

 

for Federal incom e t axes.

St a t e

You m ay specify a dollar am ount t o wit hhold for st at e t axes. However, for som e st at es, m andat ed t ax

wit hholding m ight override specific elect ions.

Hardship wit hdrawals are considered t axable incom e.

Do NOT wit hhold St at e incom e t axes.

Wit hhold St at e incom e t axes.

Wit hhold $

 

for St at e incom e t axes.

Se ct ion V I – Spe cia l I n st r u ct ion s

Se ct ion V I I – Pa r t icipa n t Au t h or iz a t ion

Ir e qu e st a h a r dsh ip w it h dr a w a l t o be m a de in a ccor d a n ce w it h t h e Pla n D ocu m e n t , I n t e r n a l Re v e n u e Code , a n d m y e le ct ion f or a n im m e dia t e a n d sig n if ica n t f in a n cia l n e e d, a s ou t lin e d in t h e H a r d sh ip

Gu ide . I n a ddit ion , t h e I RS a llow s m e t o in clu de in t h e h a r dsh ip w it h d r a w a l a m ou n t s n e ce ssa r y t o pa y a n y f e de r a l, st a t e , or loca l in com e t a x e s or pe n a lt ie s r e a son a bly a n t icipa t e d a s a r e su lt of t h is

w it h dr a w a l. M y ch oice t o w it h d r a w a d dit ion a l f u n d s f or t a x e s is in de pe n de n t of m y ch oice f or a ct u a l t a x w it h h oldin g s.

I hereby irrevocably request and consent t o a hardship dist ribut ion from m y account on t he t erm s st at ed above.

Under penalt ies of perj ury, I cert ify t hat t he above inform at ion is correct and m y social securit y num ber shown on t his form is m y correct t axpayer ident ificat ion num ber .

Icert ify any funds request ed for hardship reasons:

Will not exceed t he am ount of t he im m ediat e financial need plus t he am ount needed t o pay any t axes and penalt ies on t he wit hdrawal.

Will be used exclusively t o sat isfy t he financial need.

Have not previously been r equest ed wit h t he at t ached docum ent at ion.

I furt her cert ify t hat I hav e obt ained all loans and ot her wit hdrawals available t o m e from m y em ployer - sponsored ret irem ent plan( s) .

I furt her cert ify t hat t he financial need giving rise t o t his hardship cannot be relieved by:

reasonable liquidat ion of m y asset s, or t hose asset s of m y spouse and m inor children which are reasonably

available t o m e, t o t he ext ent such liquidat ion would not it self cause an im m ediat e and heavy financial need; cessat ion of deferral cont ribut ions t o t his em ployer - sponsored ret irem ent plan;

any available insurance reim bursem ent ;

any com m ercial loans available.

Par t icipant Signat ur e

Dat e

5

8 7 3 4 3 ( Rev 02 – 12 / 13)

Page 3 of 3

©

2013 Wells Far go Bank, N. A. All r ight s r eser ved.

 

N o tary Ad d e n d u m

Part icipant Nam e:Plan Code:SSN( last 4)

Before w e can process your request , w e w ill need t he follow ing docum ent at ion:

For disbursem ent s less t han $ 400,000, you w ill need t o sign and ret urn t he at t ached Not arizat ion .

For disbursem ent s $ 400,000 and above, you w ill need t o sign and ret urn t he at t ached Not arizat ion, AN D

phot ocopy of a governm ent issued I D.

For address changes, you w ill need t o sign and ret urn t he at t ached Not arizat ion, AN D phot ocopy of a governm ent issued I D.

Accept able form s of governm ent issued I D’s include:

Driver's Licenses or ot her st at e phot o ident it y cards issued by Depart m ent of Mot or Vehicles ( or equivalent ) for t he sole purpose of ident ificat ion, and not for evidence of em ploym ent st at us, st udent st at us, w eapons perm it , or ot her st at us.

Passport

Milit ary I D

Nat ive Am erican Tribal Phot o I D

Failure t o have t his form properly not arized m ay furt her delay t he processing of your dist ribut ion request . Your ret irem ent account rem ains invest ed per your invest m ent direct ives while t his form and ot her inform at ion is gat hered and reviewed for com plet eness, and is subj ect t o m arket volat ilit y . You m ay wish t o consider how your ret irem ent account is invest ed while your dist ribut ion is being processed. I f you would like t o change your invest m ent elect ions, please visit wellsfargo. com or call t he Ret irem ent Service Cent er at 1- 800- 728- 3123.

This inform at ion is for educat ional purposes only and does not const it ut e invest m ent , financial, t ax, or legal advice. Please cont act an invest m ent , financial, t ax, or legal advisor regarding your specific sit uat ion.

Ple a se m a il a ll docu m e n t a t ion a n d t h is a dde n du m t o t h e follow in g a d dr e ss, or fa x t o ( 3 3 6 ) 7 7 3 - 6 7 2 6 ( At t n : D a ily D ist r ibu t ion Un it ) :

Wells Fargo I nst it ut ional Ret irem ent and Trust Daily Dist r ibut ion Unit

D1118 - 026

1525 West W. T. Harris Blvd. Charlot t e, NC 28262 - 8522

Part icipant or Beneficiary Signat ur eDat e

W it n e ss t o Pa r t icipa n t ' s Sign a t u r e

N ot a r y Pu blic:

STATE OFCOUNTY OF

I , a Not ary Public in and for said Count y and St at e, acknow ledge t hat

( Part icipant ’s Nam e)

know n t o m e ( or sat isfact orily proven) t o be t he per son w hose nam e is subscribed above, appear ed before m e on

t his

 

day of

 

, 20

 

, and signed t he above consent in m y presence.

 

 

 

 

 

 

 

 

 

 

 

 

Not ary Public Signat ure:

 

 

 

 

 

 

 

My Com m ission Expires:

 

 

 

 

 

 

 

Not ary Seal:

 

 

 

 

 

592286 ( Rev 01 – 07/ 14)

 

 

 

 

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