SM4K 42649 600000124084817
BLAKE A BREWER Confirmation 213051020W038
1904 WEST 75TH PLACE Request ID 600000124084817
Transaction HARDSHIP WITHDRAWAL -
DAVENPORT IA 52806 SPONSOR APPROVED
Plan Number 42649
Plan Name STERILITE CORP.
Don't let your request expire! Complete, SIGN and return ALL pages of this application and required documents in time to
arrive by 12/01/2021.
Questions? Go to http://netbenefits.401k.com or call 800-835-5097
Hardship
Helpful To Know
• Accuracy and completeness matter! If you do not consequences. You may want to consult a tax or
financial professional.
attach valid proof of eligible expenses, your
request will be reduced or denied. • For more detail about which of your assets will be
sold for this distribution, visit the website above.
• If the market value of your account declines before
your request is processed, your distribution could be • If the available amount in your account is less than
less than is shown in this form. the amount you requested, we will distribute only the
available amount.
• Workplace retirement plan distributions may have tax
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4.DC-CS-PWK Page 1 of 4 HWPB
HWPB2 BLAKE A BREWER Request ID 600000124084817 Plan Number 42649 Control 213051020W038 Amount $3,600.00
Hardship
Distribution Details
Any federal tax withholding shown below reflects your request or applicable law. Each state sets its own withholding rates and requirements
on taxable distributions. Any state tax withholding shown below reflects either your request or applicable state law.
Terms of Request Values Could be lower if your account value changes.
Request Date 11/01/2021 Cash
Requested Amount $3,600.00 Withdraw as Cash $3,600.00
Taxable Amount $2,296.42 Includes any tax withholding.
Federal Tax Withholding Yes Federal Tax Withholding $229.64
Includes any amount withheld at your request
State Tax Withholding Yes IA State Tax Withholding $114.82
Includes any amount withheld at your request
Delivery
Delivery Method Electronic Sent electronically to your
account. Allow 3 business days after Fidelity Estimated Amount you will Receive $3,255.54
receives all required materials back from
you. Withholding amounts do NOT include early withdrawal penalties, which you
could owe because you are under age 59½.
Documenting Your Distribution Reason
You MUST provide acceptable documentation to support your requested amount. Below are the expenses your plan rules
allow you to claim and the types of documentation to submit. Documentation that is not acceptable will not be
considered. We cannot distribute more than the amount you requested, even if you supply documentation for a
higher amount.
Post-Secondary Education
Required Documentation Action Steps
o MUST include a term/semester or start/finish date, identifying current o Underline the term/semester or start/finish dates on your supporting
enrollment or active enrollment within the next 12 months documentation
o MUST include the student's name o Underline the student's name on your supporting documentation
o MUST include copies of the following which show the actual (not o Underline the actual $ amount due on each/all of your supporting
estimated) amount(s) due: documentation (tuition/room & board/books)
• Tuition: Itemized invoice or receipt for tuition/fees (must be on
school stationary or printout of an online account statement)
• *Room & Board: Copy of lease that includes landlord's name,
address, the monthly payment $ amount, and term of lease
• *Books: Dated receipt
*Additional information required for Room & Board and Books: Proof of
registration, which can include a copy of tuition invoice/receipt or a class
schedule that includes the institution's name
o Total amount from all supporting documentation MUST be close to the o Enter the total amount from all supporting documentation:
Requested Amount in the "Distribution Details" section. Your plan's rules
may provide a gross up % to account for tax withholding. $____________________ Ensure this amount is close to the
Requested Amount in the "Distribution Details" section
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4.DC-CS-PWK Page 2 of 4
HWPB3 BLAKE A BREWER Request ID 600000124084817 Plan Number 42649 Control 213051020W038 Amount $3,600.00
Hardship
Note: Financial Aid award letters or a generic list of expenses from the school's website will not be considered for reimbursement
Eligible Individuals: Participant, spouse, children, dependents (as defined by the IRS), primary beneficiary (if allowed by Plan)
Eligible Expenses: Tuition, fees, books, room & board (Note - See Internal Revenue Code (IRC) section 213(d) for a full list of eligible expenses)
Ineligible Expenses: Student loan payments, student loan payoff
Signature and Date You must sign and date.
By signing below, you:
• Certify that the hardship represents whether qualified or nonqualified, • Authorize Fidelity to act on all
an immediate and heavy financial maintained by the employer; and instructions given on this form.
need and the amount requested is that you have insufficient cash or • Certify that all information you have
necessary to satisfy that financial other liquid assets reasonably provided, including all attached
need. available to satisfy your financial documentation, is true, authentic and
• Represent that you have obtained all need. correct to the best of your
other currently available distributions • Certify that this withdrawal is being knowledge, that you have not
(including distributions of ESOP taken for you or for a family member previously requested and received a
dividends under Internal Revenue or dependent as defined by the IRS hardship withdrawal for the
Code section 404(k), but not (in the Internal Revenue Code expense(s) submitted as part of this
hardship distributions) and section 152) or your primary request, and that you have satisfied
nontaxable loans (if required by the beneficiary(ies) as designated under all the requirements for a hardship
Plan) under this Plan and all other the plan and as allowed by your withdrawal under the terms of your
plans of deferred compensation, plan. Plan.
Your Name BLAKE A BREWER
Your Signature Required Date MM DD YYYY Daytime Phone Number NNN-NNN-NNNN
Plan Sponsor Approval
By signing below, you:
• Acknowledge that the transaction as requested on this form is permitted by the Plan.
• Certify that you have been authorized by the Plan's Named Fiduciary to sign on behalf of the Plan.
Print Plan Representative Name
Sign Plan Representative Name Date MM DD YYYY
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4.DC-CS-PWK Page 3 of 4
HWPB4 BLAKE A BREWER Request ID 600000124084817 Plan Number 42649 Control 213051020W038 Amount $3,600.00
Hardship
AVOID PROBLEMS WITH YOUR REQUEST!
Use this checklist to be sure your request is complete:
o SIGN the form. Mail
Human Resources
o Attach copies of acceptable documents STERILITE CORPORATION
backing up your request. 30 Scales Ln
o Write your last name and 600000124084817 Townsend MA 01469
(your request ID number) on any documents
that you attach.
o Remember to return the ENTIRE application
including the first page and all necessary
documents.
Still have questions?
Call 800-835-5097 (TTY, 1-888-343-0860), business days (except
NYSE holidays) from 8:30 a.m. - 8:30 p.m. ET or go to
http://netbenefits.401k.com.
On this form “Fidelity” shall mean Fidelity Investments Institutional Operations Company, Inc., 245 Summer Street, Boston, MA 02210 644058.12.0
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4.DC-CS-PWK Page 4 of 4
