Understanding the complexities and options within the SUPERVALU STAR 401(k) Plan can be challenging, especially for members facing financial hardship. The Hardship Withdrawal Form, a critical component of this plan, outlines the process for members to request a withdrawal under dire financial circumstances. This form details the necessary documentation required to support various types of hardship such as medical expenses, educational fees, or the need to prevent foreclosure. Importantly, it advises on the repercussions of such a withdrawal, including a mandatory pause on contributions to the plan and the potential tax implications. Furthermore, the form provides clear instructions on how to elect for tax withholdings and the specifics about receiving the withdrawal amount. With thorough information on eligibility requirements and procedural steps, including how to submit supporting documentation and how the applications are processed, this form aims to guide members through a difficult period with as much ease as possible. Completing and submitting this form correctly is crucial to avoid delays or denials, ensuring members receive the support they need in a timely manner.
| Question | Answer |
|---|---|
| Form Name | Form Star 401 K |
| Form Length | 3 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 45 sec |
| Other names | Voya, HARDSHIPwItHDRAwAlFoRM, SV870105HARDSHN, 1-888-STAR-088 |
StAR401(k)PlAN
INStRuctIoNS
HARDSHIPwItHDRAwAlFoRM
Attached please find an application for the hardship withdrawal from your SUPERVALU STAR 401(k) PLAN.
•Review the application and review the Hardship Withdrawal Instructions.
•Sign and date the application form. Please include your phone number in the space provided.
•Voya FinancialTM will mail an IRS Form 1099R to you early next year, if your application is approved.
•Mail your Hardship application and supporting documentation to the following address:
REGULAR MAIL |
OVERNIGHT MAIL |
Voya Institutional Plan Services |
Voya Institutional Plan Services |
SUPERVALU STAR 401(k) PLAN |
SUPERVALU STAR 401(k) PLAN |
Plan Administration Unit |
Plan Administration Unit |
P.O. Box 24747 |
One8900HeritageFreedomDriveCommerce Parkway |
Jacksonville, FL |
NorthJacksonville,Quincy,FLMA322560 |
Hardship withdrawal applicants must send supporting documentation such as eviction notice, copies of medical bills with an explanation of benefits, college tuition bills, or executed contract of sale. Please see attached Hardship Withdrawal Instructions for more details.
Voya will process the application if received in a timely manner and the application is determined to be in good order. Voya will process the transaction and send the check directly to you. Voya will inform payroll to suspend contributions to your SUPERVALU STAR 401(k) PLAN for the next 6 months. If disapproved because of missing documentation or ineligible hardship reasons, you will be notified in writing.
Please note: Documentation must be complete and in good order to process your request. An incomplete application will cause a delay in receiving your check.
Name ________________________________________________________________________________________________________
FIRSTMIDDLE INITIALLAST
Street Address __________________________________________________________________________________________________
City __________________________________________________________________ State______________ Zip Code __________
Social Security Number _ _ _ - _ _ - _ _ _ _ or Employee ID _ _ _ _ _ _ Birth Date |
________________________________________ |
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Daytime Phone ( |
)___________________________________ Evening Phone: ( |
)___________________________________ |
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SV870105HARDSHN
StAR401(k)PlAN
HARDSHIPwItHDRAwAlFoRM
The Plan allows hardship distributions only under the following Internal Revenue Code Safe Harbor Regulations for immediate and heavy financial needs. Please choose the one applicable to your circumstance:
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REASON |
REQUIRED DOCUMENTATION |
INFORMATION THAT MUST BE REFLECTED |
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ON DOCUMENTATION |
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❏ Unreimbursed medical expenses for |
• Explanation of Benefits (EOB) - Must be |
• EOB |
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medical care described in IRC section 213(d) |
dated with in past 2 years and reflect |
• Must be dated within the past 2 years, and |
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previously incurred or necessary to obtain |
amount paid by the insurance company |
• Must reflect the amount paid by the insurance |
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medical care described in section 213(d) for: |
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company, and |
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____ You, or |
• Corresponding bill from the provider |
• Must reflect the amount owed by the insured |
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____ Your spouse, or |
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• Corresponding bill |
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____ Your dependents |
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- Must be dated within the past 90 days, and |
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(as defined in section 152)* |
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- Must indicate the amount still due by the |
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insured |
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❏ Tuition, related educational fees, room |
• Itemized tuition bill, and/or Room and |
• Must be dated within 4 months of the |
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and board for the next semester or |
board statement provided by the school |
beginning of the quarter or semester. |
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quarter of |
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____ You, or |
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____ Your spouse, or |
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____ Your children, or |
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____ Your dependents |
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(as defined in section 152)* |
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❏ Purchase of your principal residence |
• Signed purchase contract, or |
• Must be dated within last 30 days, and |
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• |
• Must reflect your name as the buyer, and |
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• If building, copy of builder's contract |
• Must reflect the address of the residence being |
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purchased, and |
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• Must reflect the purchase price, and |
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• Must reflect the amount of the down payment, |
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and |
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• Must reflect a closing date no more than 6 |
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months in the future, and |
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• Must reflect signatures of both buyer and seller |
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❏ Repair of principal residence that would |
• Billing statement |
• Must be dated within last 4 months, and |
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qualify as a casualty deduction such as a |
• Letter from insurance company stating |
• Must reflect the amount necessary to repair |
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fire or storm |
what is not covered from the casualty loss |
principal residence |
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❏ Prevention of mortgage foreclosure |
• Bank/mortgage statement, or |
• Must be dated within last 4 months, and |
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or eviction from your principal residence |
• Letter from bank/mortgage company, or |
• Must reflect the amount necessary to prevent |
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• Letter from landlord, or |
foreclosure or eviction, and |
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• Copy of the court document |
• If statement or letter, must threaten eviction or |
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substantiating the eviction or foreclosure |
foreclosure and |
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legal proceedings |
• Document must contain eviction/foreclosure |
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date. This date must be in the future |
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• Letter of instruction detailing the time period of |
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missed payments |
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❏ Funeral/Burial expenses for: |
• Funeral/burial billing statement |
• Must reflect name of deceased, and |
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____ You, or |
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• Must reflect date of services provided within the |
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____ Your spouse, or |
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past 90 days, and |
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____ Your children, or |
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• Must reflect your name as individual billed; and |
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____ Your dependents |
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• Must include itemized funeral/burial expenses |
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(as defined in section 152)* |
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*Without regard to the gross income exclusion of section 152 (d)(1)(B). (Generally those who you claim as dependents on your federal tax return) |
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SV870105HARDSHN |
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StAR401(k)PlAN
HARDSHIPwItHDRAwAlFoRM
In addition:
•The distribution cannot exceed the amount of your immediate and heavy financial need. The amount of your immediate and heavy financial need may include any amounts necessary to pay any federal, state, or local income taxes or penalties reasonably anticipated to result from the distribution.
•You will be prohibited from making any elective contributions to the plan for 6 months after receipt of the hardship distribution.
•You must have exhausted all other loan and withdrawal options available to you under the Plan.
•You can not remit multiple hardship requests for a time period that was previously submitted.
If you complete and return this form, you are certifying that you acknowledge and meet the Plan requirements.
Amount of Withdrawal: $____________________________
If you would like all or a portion of your Company Stock
Federal and State Withholding* Election
Elect only one option.
❏I elect 10% federal income tax withholding and any applicable state tax withholding. (or)
❏I elect to have no federal income tax or applicable state tax withheld. (or)
❏I elect _______% (enter percentage desired) federal income tax withholding and _______% (enter percentage desired) state tax withholding (if applicable). (or).
❏I elect $___________ (enter specific dollar amount) of federal income tax withholding and $___________ (enter specific dollar amount) state tax withholding (if applicable).
If no election is indicated above, 10% federal income tax and applicable state tax will be withheld.
Note: Notwithstanding the above election, state income tax will be withheld if required.
Company Stock Fund - Dividend Option
In order to receive a hardship distribution, your dividend option on the Company Stock Fund must be set up as a direct payment. As a result, if your hardship is approved and you are not currently set up to receive your Company Stock dividend in cash, this election will automatically be set up on your account.
I hereby authorize SUPERVALU and Voya to contact any person or business to confirm the facts and conditions contained in this application, including all attachments. I certify that all the information contained in this application is true and correct.
Participant Signature ______________________________________________________ Date: ___ /___ /___
If you have any questions, you may call the SUPERVALU STAR 401(k) PLAN Information Line at
How would you like to receive your withdrawal?
❏First Class Mail at no additional charge.
❏Overnight Delivery. I understand I will pay a non refundable fee of $20 which will be deducted from my account.
❏ACH Note: You must already have banking information on file with the Plan for at least 7 days in order for this payment to be directly deposited to your bank via automated clearing house.
*Withholding Tax Notice
Please review carefully since taxes withheld are remitted to the internal Revenue Service as soon as a distribution occurs and cannot be returned.
I understand that the hardship withdrawal is not eligible to be rolled over and that unless I elect not to have taxes withheld, 10% of the taxable portion of my distribution will be withheld and remitted to the internal Revenue Service (IRS). Depending upon my tax status, I may owe additional taxes on this distribution.
I understand that I may defer my distribution at least thirty (30) days after receipt of Special Tax Notice. By electing to take a distribution or initiating a direct rollover now, I am waiving this
I understand that my distribution may also be subject to state income tax and that I may elect not to have state income withholding apply to my withdrawal. If I do not elect to have state income taxes withheld, I may be responsible for payment of an estimated state income tax.
A portion of this distribution may also be subject to the 10% penalty tax under the Internal Revenue Code for early withdrawals. This penalty tax is in addition to federal and state income taxes.
6/30/201409/01/2014
SV870105HARDSHN