0423 Form 15417-H (PDF) — verbatim text

Official source: IRS Forms, Instructions & Publications (https://www.irs.gov/pub/irs-pdf/f15417h.pdf), retrieved 2026-10-03. U.S. Government work (17 U.S.C. § 105).

403(b) Plan

Distributions¶

Worksheet 15 – Determination of 403(b) Status

Instructions - All items must be completed. A “Yes” answer generally indicates a favorable conclusion is warranted, while a “No” answer indicates a problem exists. Use the space on the worksheet to explain any “No” answer. The technical principles in this worksheet may be changed by future regulations or guidelines.

The technical principles in this worksheet may be changed by future regulations or guidelines

Name of plan

I. Permissible distribution events for elective deferrals (including designated Roth contributions)	Plan Reference	Yes	No	N/A
a. Does the plan provide that elective deferrals are maintained in a separate account? If yes, then the only distribution restrictions for the elective deferral account are the ones listed in this section I. If there is no separate elective deferral account, then distributions from the participant’s account may not be made earlier than the later of any date under this section I and any date applicable under sections II and III below
b. General rule. Except for situations described in section c below, does the plan provide that 403(b) elective deferrals may not be distributed earlier than one of the following events Note to Reviewer: Not all the events below need to be included in the plan. Use N/A if not included, and use No, if it is not properly included (for example, using age 59, instead of 59 ½).
i. Death
ii. Disability
iii. Severance from employment
iv. Attainment of age 59½, or
v. Participant hardship
A. Does the plan provide whether hardship distributions of elective deferrals are permitted under the plan Note: Although the plan may incorporate by reference specific terms and conditions for hardship distributions set forth in the investment arrangements, the plan document itself must set forth all the Code requirements for hardship distributions.
B. Does the plan provide that hardship distributions may be made under the safe harbor standard of section 1.401(k)-1(d)(3) and 1.403(b)-6(d)(2); or
C. Does the plan provide an alternative standard for hardship distributions that is nondiscriminatory and based on objective criteria
c. Special situations. Except for situations described in section b above, does the plan provide that 403(b) elective deferrals may not be distributed earlier than one of the following events Note to Reviewer: Not all the events below need to be included in the plan. Use N/A if not included, and use No, if it is not properly included.
i. Termination of the plan
ii. Pre-1989 elective deferrals (not earnings thereon)

Explain any "No" answers in this section

Page 2

Page 3

Explain any "No" answers in this section

Page 4

Explain any "No" answers in this section

Page 5

Explain any "No" answers in this section

Form 15417-H (4-2023) Catalog Number 94036G publish.no.irs.gov Department of the Treasury - Internal Revenue Service

Exceptions & meaning →