Exhibit 4.5
THRIFT-INCENTIVE PLAN (TIP) FINANCIAL HARDSHIP WITHDRAWAL REQUEST
1. PARTICIPANT INFORMATION
Name Social Security Number
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Home Address City State Zip
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Work Telephone Number Home Telephone Number Location
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2. INDICATE THE REASON(S) AND AMOUNT NEEDED
(SEE ATTACHMENT FOR REQUIRED DOCUMENTATION.)
PURCHASE OF A PRIMARY RESIDENCE
MEDICAL OR DENTAL EXPENSES FOR YOURSELF OR DEPENDENTS NOT COVERED BY INSURANCE
TUITION (ROOM, BOARD AND FEES FOR SECONDARY EDUCATION FOR YOURSELF OR DEPENDENTS
PREVENTION OF EVICTION OR FORECLOSURE OF YOUR RESIDENCE
FUNERAL EXPENSES FOR MEMBER OF YOUR IMMEDIATE FAMILY
DOCUMENTED AMOUNT REQUESTED $ PLUS 20%, 30%, OR 40%
(CIRCLE ONE IF DESIRED) TO COVER POSSIBLE TAXES AND PENALTIES.
3. CHOOSE FINANCIAL HARDSHIP WITHDRAWAL METHOD
FACTS AND CIRCUMSTANCES METHOD: You can avoid restrictions on your
contributions and foregoing Company Match by certifying that you have no
other way to meet your financial need. By checking this box and signing the
bottom of this form, I AGREE THAT I HAVE NO OTHER FINANCIAL RESOURCES TO
MEET THE FINANCIAL HARDSHIP NEED LISTED BELOW. I acknowledge that financial
resources includes (but is not limited to):
Investments owned by myself or my spouse and dependents.
A loan or regular withdrawal from TIP. If you have a loan available, it
must be taken before the hardship can be processed.
A loan from a service outside of TIP.
I will not be reimbursed from insurance, litigation, scholarships, my
employer or other resources.
SAFE HARBOR METHOD: By checking this box and signing the bottom of this
form, I AGREE THAT MY CONTRIBUTIONS WILL BE SUSPENDED FOR A ONEYEAR PERIOD
AFTER MY HARDSHIP WITHDRAWAL. I further acknowledge that in the year my
contributions are eligible to resume, the maximum amount I can contribute
on a beforetax basis will be limited to the IRS maximum allowable less my
beforetax contribution in the year i took the financial hardship
withdrawal. In addition, I understand that I WILL NOT BE ELIGIBLE FOR ANY
COMPANY MATCHING CONTRIBUTION FOR THE PERIOD OF MY SUSPENSION FROM TIP.
4. CERTIFICATION AND ACKNOWLEDGMENT
I have made every attempt to provide complete and accurate information on this
application. I understand that any intentional misrepresentation of facts or
circumstances relating to this financial hardship withdrawal application or the
intentional withholding of relevant information is a major violation of Company
policy and will result in disciplinary action and could lead to termination of
employment.
Signature Date
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See attachment for type of documentation required, rollover information and
special tax notices. If you have any additional questions, you may phone
1-800-291-PLAN (7526).
RETURN TO: TIP ADMINISTRATION, HA-00
DOCUMENTS REQUIRED FOR FINANCIAL HARDSHIP REQUEST
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PURCHASE OF A PRIMARY RESIDENCE AS DEFINED BY:
A single family dwelling, condominium or cooperative unit in which you reside
year round on an ongoing basis and hold ownership.
REQUIRED DOCUMENTATION:
- -REAL ESTATE CONTRACT: Signed and accepted for the construction or purchase of
a primary residence.
- -GOOD FAITH ESTIMATE: Needed to include closing costs as part of your financial
hardship.
- -"NO LOANS LETTER": Needed if your mortgage lender will not allow you to use
TIP loan funds as part of the down payment, have your
lender state that in a short letter.
- -EXPECTED PROCEEDS
ESTIMATE: Needed if selling an existing home, obtain an expected
proceeds estimate.
UNINSURED MEDICAL/DENTAL EXPENSES FOR CHILDREN, SPOUSE OR SELF AS DEFINED BY:
Noncosmetic medical and dental expenses not covered by an insurance plan.
Expenses that must be paid to obtain medical or dental treatment.
REQUIRED DOCUMENTATION:
- -"EXPLANATION OF BENEFITS": Statement from insurance carrier(s) indicating
breakdown of charges not covered by insurance.
- -Proof that payment must be made to obtain treatment in the event that you do
not have medical and/or dental insurance, bills from the doctor or dentist will
be accepted as documentation. We reserve the right to contact the physician
and/or dentist to verify services performed.
TUITION (ROOM, BOARD AND FEES) FOR SECONDARY EDUCATION FOR YOURSELF OR
DEPENDENTS AS DEFINED BY:
Current or future tuition expenses for you, your spouse and/or children for
current year postsecondary tuition, including room, board and fees. (college,
university or vocational school)
REQUIRED DOCUMENTATION:
- -Proof from educational institution that the student has been accepted for
admission or currently enrolled, i.e., student I.D. card, letter of admission,
canceled tuition checks or receipts.
- -Verification of tuition expenses, room, board and fees. This can be in a form
of a list of courses to be taken and a page from the current school year catalog
or manual which itemizes expenses, or a written confirmation of itemized
expenses from the school (along with any canceled checks/receipts)
PREVENTION OF EVICTION OR FORECLOSURE OF YOUR RESIDENCE AS DEFINED BY:
Rent or mortgage payment on a primary residence.
REQUIRED DOCUMENTATION: -Letter of eviction reflection amount and number of
months that the rent is past due.
-Notice of foreclosure from mortgage company reflecting
amount and number of months mortgage is past due.
BURIAL EXPENSES FOR MEMBER OF YOUR IMMEDIATE FAMILY AS DEFINED BY:
Parents, spouse, children, siblings and/or dependent
REQUIRED DOCUMENTATION: -Documented death notice
-Signed estimated charges for burial.