To submit this form, complete all applicable sections and obtain any required signatures. Send the form along with supporting documentation to Transamerica, 6400 C Street SW, Cedar Rapids, IA 52499, or fax it to 833-200-9987. For questions or assistance, you can call 800-755-5801. Ensure all fields are filled accurately and supporting documents are enclosed to avoid processing delays. It is advisable to keep a copy of the form and any submitted documents for your records.

The primary purpose of this form is to enable employees of Appalachian Regional Healthcare to request a hardship withdrawal due to immediate and heavy financial need. This form ensures that employees can access their Thrift Plan funds to cover significant expenses such as preventing foreclosure, paying for medical or education expenses, and other pressing financial obligations. By providing detailed information and necessary documentation, the form helps streamline the request process and ensures compliance with plan provisions. Completing this form accurately and thoroughly will help expedite the withdrawal process and ensure that employees receive the financial assistance they need in a timely manner.

• 1. Plan Sponsor Information: Includes the Plan Name, Contract/Account Number, Affiliate Number, and Division Number.
• 2. Personal Information: Includes Social Security Number, First Name, Last Name, Date of Birth, Mailing Address, City, State, Zip Code, Phone Number, Extension, and E-mail Address.
• 3. Hardship Withdrawal Information: Specifies the amount to be withdrawn and the reason for the financial need, with options for adding taxes to the distribution amount.
• 4. Supporting Documentation: Lists the types of financial needs and the corresponding documentation required to support the withdrawal request.
• 5. Payment Options: Includes options for Direct Deposit to bank account or Check, with important notes on processing times and policies.
• 6. Tax Withholding: Details federal and state income tax withholding options and requirements.
• 7. Participant Signature: Requires the participant's signature, date, printed name, and Social Security Number.
• 8. Spousal Consent: Includes the spouse's consent to waiver of survivorship benefits, signature, and date, witnessed by a Plan Sponsor or Notary Public.

Failure to submit this form may result in an inability to access the necessary funds to address your financial hardship. Completing and submitting the form accurately and promptly ensures you can receive the appropriate withdrawal.

• Delayed Access to Funds: You may experience delays in accessing the funds needed to address your financial situation.
• Non-Compliance: Incomplete or incorrect form submission may lead to non-compliance with plan provisions and regulatory requirements.

• 1. Prevent Foreclosure or Eviction: Use this form to withdraw funds needed to prevent foreclosure on or eviction from your principal residence.
• 2. Purchase Principal Residence: Submit this form when you require funds for the purchase of your principal residence, excluding mortgage payments.
• 3. Educational Expenses: Apply for a hardship withdrawal to cover post-secondary education expenses for yourself or eligible family members.
• 4. Medical Expenses: Request a withdrawal to cover qualifying unpaid medical expenses for yourself, spouse, dependents or primary beneficiaries.
• 5. Burial/Funeral Expenses: Use the form to obtain funds to cover burial or funeral expenses for a deceased parent, spouse, child, dependent, or primary beneficiary.