Fillable CORONAVIRUS-RELATED DISTRIBUTION FORM Puget Sound Electrical Workers 401(k)

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CORONAVIRUS-RELATED DISTRIBUTION FORM Puget Sound Electrical Workers 401(k)

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Puget Sound Electrical Workers 401(k) Savings Plan
CORONAVIRUS-RELATED DISTRIBUTION FORM
PARTICIPANT
’S NAME
SOCIAL SECURITY NO.
PARTICIPANT’S ADDRESS
LO1305
Page 1 of 4
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***
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If you are currently out-of-work, and have been impacted by COVID-19, you may be eligible to request a distribution of
up to $50,000 from the Plan (or your full account balance if less). To meet these requirements, you must:
1. Establish Out-of-Work Status
To request a COVID-19 related distribution under the PSEW 401k Trust, you need to establish that you are currently
out-of-work. This can be done as follows:
I have been laid off and am currently on the IBEW Local 46 out-of-work list. (Out-of-work status
will be confirmed with IBEW Local 46 before any COVID-19 distributions will be approved.)
I am on furlough or stand-by status and not presently working. (Out-of-work status will be
verified with your employer before any COVID-19 distributions will be approved.)
Name of Most Recent Employer
Last day emp
l
oyed
2. Confirm Coronavirus Impact
Distributions available under the Coronavirus Aid, Relief, and Economic Security Act (“CARES Act”), receive special tax
treatment. For a COVID-related distribution, you must also certify that any of the following criteria are true:
You, your spouse, or your dependent have been diagnosed with the virus SARS-CoV-2 or with coronavirus
disease 2019 (COVID-19) by a test approved by the CDC (Centers for Disease Control), or
Due to the coronavirus, you suffered adverse financial consequences because of:
o Being quarantined, furloughed, laid off, or having your work hours reduced, or
o Your inability to work due to lack of childcare, or
o The closing of or reduction of hours with respect to a business you own or operate, or
o Other factors as provided in guidance issued by the Internal Revenue Service
Most participants in the PSEW 401(k) Plan who have been laid off, furloughed or are otherwise unemployed after April 1,
2020 will meet the COVID-19 related requirements. To ensure proper tax treatment of your distribution, however, the
IRS requires you to confirm that you have been impacted by COVID-19 related events.
3. Coronavirus-related distributions must be paid out by December 31, 2020. Repayment within 3 Years
Permitted under the CARES Act.
Please make sure you return the form to allow for sufficient time to process your request before the deadline.
Distributions may take 2 – 4 weeks from the time we receive all of your completed forms. These special CARES Act
distributions can be repaid to the Plan within three years to assist you in replenishing retirement savings and eliminating
or reducing taxes owed.
CARES Act Certification I hereby certify due to the coronavirus or COVID-19 that I meet the criteria as stated above.
Signature_________________________________________________ Date___________________________________
Return all forms to: PSEW 401(k) - P O Box 34203, Seattle WA 98124
End 1
Puget Sound Electrical Workers 401(k) Savings Plan
CORONAVIRUS-RELATED DISTRIBUTION FORM
PARTICIPANT’S NAME
SOCIAL SECURITY NO.
LO1305
Page 2 of 4
This special distribution is taxable but may be included in your income spread out evenly over a three-year period. Unless
you elect otherwise, you will be subject to 10% withholding for federal income taxes, plus any applicable state tax
withholding. The 10% early withdrawal penalty does not apply, and the distribution may not be rolled over directly to an
IRA or retirement plan. This coronavirus-related distribution may be paid back to a retirement plan or IRA in single or
multiple payments within three years.
*A maximum of $100,000 may be distributed to you, counting all distributions from this plan and any other plans or
IRAs in which you participate. It is your responsibility to make sure the total amount of your coronavirus-related
distributions does not exceed $100,000.
I. AMOUNT OF WITHDRAWAL REQUEST
NOTE: You may obtain the dollar amount of your account available for withdrawal by contacting John Hancock.
I request a distribution from my available account in the amount of:
$_________________ (fill in dollar amount – not to exceed $50,000)
If the amount available to withdraw is less than the amount you requested, you will receive your entire available
amount.
Any amount paid to you will be reduced by applicable taxes.
II. TAX WITHHOLDING ELECTION
You may elect to have (or not have) federal income tax withheld from your distribution by checking Option A or B
below.
If you elect to have no amount withheld, or if you do not have enough federal income tax withheld, you may be
responsible for payment of estimated tax. You may incur penalties under the estimated tax rules if your
withholding and estimated tax payments are not sufficient. You should consult your tax advisor for more
information.
NOTE: If no election is made, 10% will automatically be withheld from your distribution for federal income tax,
and the appropriate percentage will be withheld for state income tax (if applicable).
Elect One
A. I elect to have federal income tax, at the rate of 10%, and state income tax (if applicable) withheld from
my coronavirus-related distribution. Additional Federal Tax Amount to be Withheld (if any; as
follows): $____________________.
B. I do not elect to have any federal or state income tax withheld from my coronavirus-related distribution.
Return all forms to: PSEW 401(k) - P O Box 34203, Seattle WA 98124
End 2
Puget Sound Electrical Workers 401(k) Savings Plan
CORONAVIRUS-RELATED DISTRIBUTION FORM
PARTICIPANT’S NAME
SOCIAL SECURITY NO.
LO1305
Page 3 of 4
III. MARITAL STATUS
I am legally married YES NO
If you checked “Yes,” your spouse must complete the attached SPOUSAL CONSENT FORM.
Spouse Name___________________________________________ Spouse Birth Date_________________________
Please print
IV. SELF-CERTIFICATION AND SIGNATURE
I certify that this request, when combined with any other coronavirus-related distributions I have received from
this plan or other plans and IRAs, does not exceed the $100,000 limit.
I understand that I have the option to have this distribution directly deposited into my bank account by accessing
mylife.jhrps.com to set up my banking information or to confirm existing banking information on file, if applicable.
I certify that there is no pending domestic relations order or court approved domestic relations order which has, or
will, assign all or a part of my vested account to my spouse, former spouse, child or other dependent. I
understand that a false statement by me may result in legal damages for which I will be fully responsible.
I also understand that the payment amount may be less than the specific dollar amount I have requested above
due to Plan limitations and/or market fluctuations that may affect the amount available for withdrawal at the time
payment is made.
Return all forms to: PSEW 401(k) - P O Box 34203, Seattle WA 98124
End 3
Continued next page
Signature of Participant______________________________________ Date________________________________
Puget Sound Electrical Workers 401(k) Savings Plan
CORONAVIRUS-RELATED DISTRIBUTION FORM
PARTICIPANT’S NAME
SOCIAL SECURITY NO.
LO1305
Page 4 of 4
Under penalties of perjury, I certify that:
1. The Social Security number / taxpayer identification number I provided on this form is my correct taxpayer
identification number.
2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not
been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a
failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup
withholding, and
3. I am a U.S. citizen or other U.S. person, including a U.S. resident alien (as defined in the IRS Form W-9
instructions).
Certification Instructions
You must check the box below if you have been notified by the IRS that you are currently subject to backup
withholding because you failed to report all interest and dividends on your tax return.
I am subject to backup withholding as a result of a failure to report all interest and dividends.
Since the Plan is an account held in the United States, you are not required to provide a code indicating that you are
exempt from FATCA reporting.
Note: The IRS does not require your consent to any provision of this document other than the certification required to
avoid backup withholding.
I hereby certify that I meet the requirements for Eligibility for Payment as stated in my request above.
Signature of Participant: ______________________________________ Date: _______________________
WITNESSED BY NOTARY PUBLIC (To be completed by Notary Public)
State of , County of , ss.
On this, the ____ day of ___________, 20__, before me personally appeared ________________________________
known (or satisfactorily proven) to me to be the person who executed the foregoing. In witness whereof, I
hereunto set my hand and official seal.
_____________________________________________________________
Signature of Notary Public (SEAL)
My Commission Expires: / /
TO BE COMPLETED BY PLAN ADMINISTRATOR
The request for the above Participant is: APPROVED NOT APPROVED
If approved, the Custodian is hereby authorized to process the request.
Plan Administrator: Date:
Date form received by Plan Administrator:
Return all forms to: PSEW 401k – P O Box 34203, Seattle WA 98124
End 4
Puget Sound Electrical Workers 401(k) Savings Plan
SPOUSAL CONSENT FORM
LO1305
Page 1 of 1
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***
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PARTICIPANT’S NAME
SOCIAL SECURITY NO.
SPOUSAL CONSENT (To be completed by the spouse of the Participant)
I certify that I am the spouse of the Participant named above. I understand that I have the right to have the Plan pay
spouse’s vested account in the form of a joint and survivor annuity (which will provide a lifetime annuity to my spouse
with continuing payments to me for my lifetime, provided that I outlive my spouse); and, I hereby agree to give up that
right. I understand that by signing this SPOUSAL CONSENT FORM, I may receive less money than I would have received
under the joint and survivor annuity and that I may receive nothing after my spouse dies, depending on the payment
form that my spouse chooses.
I certify that I am the spouse of the Participant named above. I understand that I have the right to deny my consent to
pay a distribution under the Coronavirus Aid and Economic Security Act in the form of a lump sum payment.
I have reviewed the Election of Benefits Form. I consent to the election of the Lump Sum form of payment indicated
above.
_______________________________ _______________________________ _____________________
Spouse's Name (Print) Signature of Spouse Date
(Must be signed and dated in presence of Notary)
WITNESSED BY (To be completed by Notary Public)
NOTARY PUBLIC
State of , County of , ss.
On this, the ____ day of ___________, 20__, before me personally appeared ________________________________
known (or satisfactorily proven) to me to be the person who executed the foregoing Spousal Certification and
acknowledged that he or she executed the same as his or her free act and deed. In witness whereof, I hereunto set my
hand and official seal.
____________________________________________________________________
Signature of Notary Public (SEAL)
My Commission Expires: / /
Return all forms to: PSEW 401(k) - P O Box 34203, Seattle WA 98124
End 1
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CORONAVIRUS-RELATED DISTRIBUTION FORM Puget Sound Electrical Workers 401(k)

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Completed 20 December 2021

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