GA Plan Administrators - Forms - 403(b) Plan Hardship Distribution Request Form

	403(b) Plan Hardship Distribution Request Form Please provide the following information regarding your withdrawal request. When finished, click Submit. For more information regarding distributions from 403(b) plans, please see When Can I Take a Distribution from My 403(b)?.
	Date
	Name
	E-mail Address
	Social Security No.	- -
	Phone Number
	Employer Name
	Withdrawal Amount
	Reason for the Withdrawal: Verification for the reason chosen needs be faxed to "Distribution Request" at 513.357.3199. Failure to provide verification can delay the processing of your request. Financial Hardship: My immediate and heavy financial hardship results from a need to (choose one): Pay college tuiton that is due in the next 12 months for myself or a dependent. Make a down payment on my primary residence. Pay medical expenses for myself or a dependent. Prevent foreclosure or eviction from my home.