Hardship Distribution Checklist[1]

Participant Name

Plan Name

Yes / No / N/A
  1. Has a hardship application been completed by the participant?

  1. Does the plan document permit hardship distributions?

  1. Does the plan use the safe harbor provisions in Treasury Regulation § 1.401(k)-1(d) regarding the reason for the distribution and establishing financial need?

  1. Has the participant confirmed the distribution is for one of the following:
  2. Expenses for (or necessary to obtain) medical care that would be deductible under section 213(d) (determined without regard to whether the expenses exceed 7.5% of adjusted gross income)
  3. Costs directly related to the purchase of a principal residence for the employee (excluding mortgage payments);
  4. Payment of tuition, related educational fees, and room and board expenses, for up to the next 12 months of post-secondary education for the employee, or the employee’s primary beneficiary, spouse, children, or dependents (as defined in section 152, without regard to section 152(b)(1), (b)(2) and (d)(1)(B));
  5. Payments necessary to prevent the eviction of the employee from the employee’s principal residence or foreclosure on the mortgage on that residence;
  6. Payments for burial or funeral expenses for the employee’s deceased primary beneficiary, parent, spouse, children or dependents (as defined in section 152, without regard to section 152(d)(1)(B)); or
  7. Expenses for the repair of damage to the employee’s principal residence that would qualify for the casualty deduction under section 165 (determined without regard to whether the loss exceeds 10% of adjusted gross income).

  1. If the expense is for the participant’s primary beneficiary, does the plan allow for hardship distributions for medical care, tuition or burial/funeral expenses of the participant’s primary beneficiary?

Yes / No / N/A
  1. Has the participant confirmed the amount requested is equal to or less than the amount required to satisfy the financial need (including any amounts necessary to pay any federal, state, or local income taxes or penalties resulting from the distribution)?

  1. Has the participant confirmed he or she has obtained all other currently available distributions (including distribution of ESOP dividends under section 404(k), but not hardship distributions) and nontaxable (at the time of the loan) loans, under the plan and all other plans maintained by the employer?

  1. Does the plan (or another legally enforceable agreement) prohibit the participant from making elective contributions and employee contributions to any plans maintained by the employer for at least six months after receiving the hardship distribution?

  1. If the plan is subject to the qualified joint and survivor annuity (QJSA) rules, has spousal consent been obtained?

  1. Is the participant’s account free from any hold as the result of a pending domestic relations order?

  1. If distribution is from a non-401(k) source subject to vesting, have you confirmed that the distribution will not exceed the participant’s vested balance?

  1. If a non-401(k) source will be distributed, will amounts be taken from non-401(k) sources first?

  1. Have you confirmed that the hardship distribution would not exceed the aggregate amount of the participant’s elective deferrals (without adjustment for investment gains or losses) plus any permitted non-401(k) sources as of the date of the distribution less any prior distributions of elective deferrals?

DateSignature

1

434298.5

[1] Prepared September 21, 2010.