CARES Act Certification Form
The Coronavirus Aid, Relief, and Economic Security (CARES) Act, signed into law by President Trump,
addresses several key issues introduced by the COVID-19 pandemic. The Act acknowledges the economic
impact the outbreak has had on the country and seeks to provide financial support to businesses,
employees, individuals and families. Additionally, it specifically provides guidance on retirement and
health care benefits, many of which MidAmerica administers on behalf of plan participants.
The CARES Act includes a provision that allows qualified plan participants impacted by COVID-19 to
access—free of penalty—, up to $100,000 of their retirement funds from eligible retirement plans for
distributions between January 1, 2020 and December 31, 2020; loans may also be made for a period of
180 days following the enactment and until September 23, 2020.
To be eligible for these special payments, you must certify that you are an individual (select at least one
below):
who is diagnosed with the virus SARS-CoV-2 or with coronavirus disease 2019 (COVID-19) by a test
approved by the Centers for Disease Control and Prevention,
whose individual’s spouse or dependent (as defined in section 152 of the Internal Revenue Code of
1986) is diagnosed with such virus or disease by such a test, or
who as an individual, spouse or member of the individual’s household is experiencing or has
experienced adverse financial consequences as a result of the following:
• being quarantined, furloughed or laid off or having work hours reduced due to such virus or
disease;
• having a reduction in pay (or self-employment income) due to COVID-19;
• having a job offer rescinded or start date for a job delayed due to COVID-19;
• being unable to work due to lack of child care due to such virus or disease, closing or reducing
hours of a business owned or operated by the individual, individual’s spouse or a member of
the individual’s household due to the virus or disease; or other factors as determined by the
Secretary of the Treasury (or the Secretary’s delegate).
In addition, I certify that this request, combined with any other coronavirus-related distributions or loans
I have received, or have requested from this plan or any other plan, does not exceed the $100,000 limit
on COVID-19 transactions.
Participant Name (Print) Social Security Number
Participant Signature
Date (MM/DD/YYYY)
**Please note: Please submit CARES Act Certification Form with Distribution Election Form to the address below.
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signature
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