NA4K 25100 600000084637511

KETURAH H CROFT Confirmation 191800834W157

2868 FULHAM PLACE Request ID 600000084637511
Transaction HARDSHIP
MEMPHIS TN 38128 WITHDRAWAL-SPONSOR
DIRECTED/J&S
Plan Number 25100
Plan Name TENET 401(K)

Don't let your request expire! Complete, SIGN and return ALL pages of this application and required documents in time to
arrive by 07/29/2019.

Questions? Go to www.401k.com or call 800-372-4015

Hardship
Helpful To Know
· Accuracy and completeness matter! If you do not
attach valid proof of eligible expenses, your
request will be reduced or denied.
· If the market value of your account declines before
your request is processed, your distribution could be
less than is shown in this form.
· Workplace retirement plan distributions may have tax
consequences. You may want to consult a tax or
financial professional.
· For more detail about which of your assets will be
sold for this distribution, visit the website above.
· If the available amount in your account is less than
the amount you requested, we will distribute only the
available amount.
· Please review the Expense and Documentation
Details section below. You must attach all
required documentation and complete all actions.
All distributions are subject to the Plan's rules and
requirements.

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4.DC-CS-PWK Page 1 of 8 HWPB

HWPB2 KETURAH H CROFT Request ID 600000084637511 Plan Number 25100 Control 191800834W157 Amount $5,200.00
Hardship

Distribution Details
Any federal tax withholding shown below reflects your request. 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 06/29/2019 Cash
Requested Amount $5,200.00 Withdraw as Cash $5,200.00
Taxable Amount $5,200.00 Includes any tax withholding.

Federal Withholding Yes Federal tax withholding $520.00

Includes any amount withheld at your request
State Withholding No TN state tax withholding $0.00
Includes any amount withheld at your request
Delivery
Delivery Method Check Sent by express delivery to your
mailing address. Allow 2 to 3 business days Estimated Amount you will Receive $4,680.00
after Fidelity receives all your required
materials. Withholding amounts do NOT include early withdrawal penalties, which you
could owe because you are under age 59½.
Estimated Fees Deducted from your account.

Express Delivery $25.00

Documenting Your Distribution Reasons

You MUST provide acceptable documentation to back up 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.

Look at "Expenses and Documentation Details" at the end of this form. Choose the hardship reasons that fit your situation,
then check them below and provide any required information:
o Preventing eviction/foreclosure o Out-of-pocket medical expenses
o Purchase of a principal residence o Post-secondary education
o Loss-related repairs to your principal residence o Current Funeral or Burial Expenses
Provide short descriptions of both the event and damage.

Loss-Related Event Hurricane, earthquake, etc.

Loss-Related Damage Broken windows, water damage, hole in roof, etc.

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4.DC-CS-PWK Page 2 of 8
HWPB3 KETURAH H CROFT Request ID 600000084637511 Plan Number 25100 Control 191800834W157 Amount $5,200.00
Hardship

Signature and Date You must sign and date.

By signing below, you:

· Certify that the hardship represents
an immediate and heavy financial
need and the amount requested is
necessary to satisfy that financial
need.
· Certify that no other funds are
reasonably available to address the
hardship, including potential
insurance payments or any other
distributions or nontaxable loans (if
required by your plan) that may
currently be available under all plans
maintained by your employer or a
related employer.
· Certify that this withdrawal is being
taken for you or for a family member
or dependent as defined by the IRS
(in the Internal Revenue Code
section 152) or your primary
beneficiary(ies) as designated under
the plan and as allowed by your
plan.
· Authorize Fidelity to act on all
instructions given on this form.
· Certify that all information you have
provided, including all attached
documentation, is authentic and
correct to the best of your
knowledge, that you have not
previously requested a hardship
withdrawal for the expense(s)
submitted as part of this request,
and that you have satisfied all the
requirements for a hardship
withdrawal under the terms of your
plan.

Your Name KETURAH H CROFT

Your Signature Required Date MM DD YYYY Daytime Phone Number NNN-NNN-NNNN

AVOID PROBLEMS WITH YOUR REQUEST! Ways to Return This Form to Fidelity:

Use this checklist to be sure your request is complete: Electronically

o SIGN the form. Use the Send a Document Action found in the
NetBenefits Mobile apps. under Actions Menu.
o Attach copies of acceptable documents
backing up your request. Regular mail
o Write your last name and 600000084637511 Fidelity Investments
(your request ID number) on any documents PO Box 770003
that you attach. Cincinnati, OH 45277-0065
o Remember to return the ENTIRE application
Overnight mail
including the first page and all necessary
Fidelity Investments
documents.
100 Crosby Parkway KC1F
Covington, KY 41015
Still have questions? FAX 1-877-236-8116
Call 800-372-4015 (TTY, 1-888-343-0860), business days (except Allow 2 hours for our system to validate receipt of your
NYSE holidays) from 8:30 a.m. - midnight ET or go to document (if sending electronically or faxing after 4:00PM
www.401k.com. Eastern Time, allow until the next business day). An
automatic confirmation will be sent to the email address we
have on file for you.

On this form “Fidelity” shall mean Fidelity Investments Institutional Operations Company, Inc., 82 Devonshire St., Boston, MA 02109 644058.5.0

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Page 4 of 8
Expense and Documentation Details Do NOT return this page

You MUST provide acceptable documentation to back up 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.

To ensure there is no delay in completing your request:

· Include all the Required Documentation and Action with your application
· Complete all the Action steps that are specific to your Hardship request

Preventing Eviction/Foreclosure (from Principal Residence)

Required Documentation Action Steps

o MUST be dated within the past 3 months o Underline the date on your supporting documentation

o MUST include your name or address o Underline your name or address on your supporting documentation

o MUST threaten eviction or foreclosure by the landlord or mortgage o Underline the threat which states you will be evicted/foreclosed
lender
o MUST include the $ amount due to prevent eviction/foreclosure o Underline the $ amount due to prevent eviction/foreclosure

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

Note: Landlords and mortgage companies may threaten eviction or foreclosure with various terminologies (e.g. quit premises, vacate, surrender possession,
sale of the property, locks to be changed). Examples of language which do not constitute a threat of eviction or foreclosure include loan default, delinquency,
acceleration, arrears, or a lien.

Eligible Individuals: Participant

Eligible Expenses: Principal residence only

Ineligible Expenses: Second home, vacation home, investment property

Purchase of Primary Residence

Required Documentation Action Steps

o MUST be dated within the past 3 months o Underline the date on your supporting documentation

o MUST include your name as the buyer o Underline your name on your supporting documentation

o MUST include a Purchase and Sales Agreement/contract, signed by o Underline both yours and the seller's name on the Purchase and
both you and the seller Sales Agreement/contract
o MUST include your out of pocket $ amount o Underline your out of pocket $ amount
· A Settlement Statement or Estimate of Closing Costs (from a lender or
contractor) for any related expenses not listed in the signed contract
can also be included with your supporting documentation

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

Eligible Individuals: Participant

Eligible Expenses: Examples of eligible expenses include down payment, title fees, closing costs

Ineligible Expenses: Second home, vacation home, investment property, mortgage payment(s)

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4.DC-CS-PWK Page 5 of 8
HWPB6 KETURAH H CROFT Request ID 600000084637511 Plan Number 25100 Control 191800834W157

Casualty Loss: Repair of Damages to Principal Residence

Required Documentation Action Steps

o MUST be dated within the past 12 months o Underline the date on your supporting documentation

o MUST include your name or address o Underline your name or address on your supporting documentation

o MUST include a written description of the event which resulted in
damages
o MUST include a written description of the resulting damages
o MUST include copies of receipts, invoices, or contractor estimates
reflecting the $ amount due for repairs
o Total amount from all supporting documentation MUST be close to the
Requested Amount in the "Distribution Details" section. Your plan's rules
may provide a gross up % to account for tax withholding.
o Underline the written description of the event, which resulted in
damages, on your supporting documentation
o Underline the written description of the resulting damages on your
supporting documentation
o Underline the $ amount due for repairs on your supporting
documentation
o Enter the total amount from all supporting documentation:
$____________________ Ensure this amount is close to the
Requested Amount in the "Distribution Details" section

Eligible Individuals: Participant

Eligible Expenses: Expenses to repair uninsured and unreimbursed casualty loss damage to your principal residence.See IRS Publication 547 and/or
consult with your tax advisor.

Ineligible Expenses: Second home, vacation home, investment property

Out of Pocket Medical Expenses

Required Documentation Action Steps

o MUST be dated within the past 3 months o Underline the date on your supporting documentation

o MUST include the patient's name o Underline the patient's name on your supporting documentation

o MUST provide copies of bill/receipt/Explanation of Benefits (EOB) or

other documentation of expenses recently paid, or still owed
o MUST include the specific $ amount not covered by insurance for each
bill/receipt/EOB submitted
o Total amount from all supporting documentation MUST be close to the
Requested Amount in the "Distribution Details" section. Your plan's rules
may provide a gross up % to account for tax withholding.
o Underline the $ amount not covered by insurance on each/all of your
supporting documentation
o Enter the total amount from all supporting documentation:
$____________________ Ensure this amount is close to the
Requested Amount in the "Distribution Details" section

Eligible Individuals: Participant, spouse, children, dependents (as defined by the IRS), primary beneficiary (if allowed by Plan)

Eligible Expenses: Hospital visits, ambulance services, surgery EXCEPT elective cosmetic procedures, licensed physician, dentist, or orthodontist visits,
laboratory tests ordered by a physician, prescription medicine, eye care, medically required home improvements (Note - See Internal Revenue Code (IRC)
section 213(d) for a full list of eligible expenses)

Ineligible Expenses: Reimbursed expenses, cosmetic surgery

4.DC-CS-PWK Page 6 of 8 HWPB

HWPB7 KETURAH H CROFT Request ID 600000084637511 Plan Number 25100 Control 191800834W157

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

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

Funeral or Burial Expenses

Required Documentation Action Steps

o MUST be dated within the past 3 months o Underline the date on your supporting documentation

o MUST include the name of the deceased o Underline the decedent's name on your supporting documentation

o MUST include copies of a bill, invoice, or estimate from the cemetery, o Underline the $ amount due on all of your supporting documentation
funeral home, or vendor which reflect a specific $ amount due
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

Eligible Individual: Participant, spouse, children, dependents (as defined by the IRS), primary beneficiary (if allowed by Plan)

Eligible Expenses: Funeral expenses, burial expenses

Ineligible Expenses: Prepaid expenses

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