Form Hardship Withdrawal Request – Fill Out and Use This PDF

Enter your Social Security number.

Enter your First name, MI and Last name.

Enter your Date of birth as month, day and year.

Choose one Notification Preference, Email or SMS Text. If neither email or text are selected (or both), Prudential will default to email if provided.

You request a Hardship Withdrawal for the following reason(s).

Check all that apply. 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.

Request Amount: a specific amount is required.

If the amount requested exceeds your maximum hardship withdrawal amount, you will be paid the maximum amount available.

The total maximum allowed to gross-up for federal and state tax is 35%.

Hardship disbursements are subject to 10% federal income tax withholding, unless you elect otherwise. If you do not check one of the options, 10% federal income tax withholding will be automatically deducted from your payment.

1. You elect to have federal income tax withheld at 10% from the taxable amount of your distribution.

2. You elect not to have federal income tax withheld from your distribution.

3. You elect to have federal income tax withheld from the taxable amount of your distribution at either the following percentage or dollar amount. The federal withholding calculated from your election must be at least 10% of the taxable amount of my distribution amount.

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.

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, NC, NE, OK*, OR*, VA or VT* applicable withholding will be deducted automatically, unless an election out is applicable.

If state income tax withholding is not mandatory in your state, you may be allowed to request state tax withholding.

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

Express Mail costs $25 per check; Prudential will deduct $25 from your account prior to the distribution (checked November 9, 2026).

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

If you would like your disbursement sent to you via Electronic Funds Transfer (EFT), provide the Account Number and the Financial Institution Routing/Transit/ABA Number.

Choose one Type of Account. For Checking, you must attach a voided check, or include a letter from your financial institution signed by an authorized representative, with your name, checking account number, and ABA routing number. For Savings, you must include a letter from your financial institution signed by an authorized representative, with your name, savings account number, and ABA routing number.

The Participant signs and dates the form: Participant's signature (REQUIRED).

You certify that the information provided on this form and on any attached forms is true, correct, and complete to the best of your knowledge.

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

Purchase of Principal Residence or Construction of Principal Residence (if you are using a general contractor): you must submit copies of ALL documentation requirements or your request will not be approved, including a complete copy of the purchase contract to build or purchase your principal residence, including addendums.

For tuition, for up to the next 12 months of post-secondary education: Copy of the unpaid tuition bill or signed letter from the school (on school's letterhead) with Statement date within the last 60 days.

Eviction: Copy of the eviction notice or court document with Eviction notice/court document dated within the last 60 days.

Funeral Expenses: Copy of the unpaid bill on the company's letterhead with Statement date within the last 60 days.

Copies of unpaid invoices and/or contracts with Invoice and/or contract date within the last 60 days. An estimate of these charges CANNOT be accepted.

If applicable to your account, have your spouse complete the section of the form titled "Spousal Waiver" in the presence of the notary. The notary and your spouse must sign the document on the same date.

Mail all forms and documentation to Prudential Retirement: regular mail to PO Box 5410, Scranton, PA 18505-5410; express mail to 30 Scranton Office Park, Scranton, PA 18507-1789; fax to 1-866-439-8602.