Deferred Compensation Unforeseeable Emergency Distribution Application

Transcription

1 Defeed Compensation Unfoeseeable Emegency Distibution Application Explanation & Infomation About Reuests fo Unfoeseeable Emegencies As the administative sevices povide fo you Defeed Compensation Plan, we ae pleased to povide you with infomation egading you euest fo an Unfoeseeable Emegency Distibution. A distibution on account of an Unfoeseeable Emegency may not be made to the extent that such emegency is o may be elieved though eimbusement o compensation fom insuance o othewise, by liuidation of the Paticipant s assets, to the extent the liuidation of such assets would not itself cause sevee financial hadship, o by cessation of defeals unde the Plan, o as othewise pemitted by law. Please note that the amount you euest fo a withdawal cannot exceed the cuent value of you account. If you euest is appoved, all funds will be withdawn on a po-ated basis acoss all accounts, accoding to you allocation pecentages. Some mutual funds may impose a shot tem tade fee. Please ead the undelying pospectuses caefully. If you cuently have Life Insuance coveage though the plan, please be awae that if you choose to stop you defeals to alleviate you Unfoeseeable Emegency, you policy may lapse and you coveage will no longe be in effect. Please contact ou office to discuss the options available to you to continue you life insuance coveage. Funds may only be withdawn fom Salay Reduction (pe-tax contibutions) and Roth Contibution (post-tax contibutions) money types. If you Unfoeseeable Emegency euest is appoved, funds will be withdawn fom you account on a poated basis acoss both money types, if applicable. Eanings fom Roth Contibutions ae only consideed tax fee when you each age 591/2 and five yeas afte the fist Roth contibution. Please MAIL the completed application and suppoting documentation to: NATIONWIDE RETIREMENT SOLUTIONS P O BOX COLUMBUS OH If you pefe, you can FAX the completed application and suppoting documentation to If you euie assistance with the completion of this fom o have any uestions, please call us at NRS-FORU ( ). 1 Nationwide Retiement Solutions P.O. Box Columbus, Ohio

2 Pesonal Infomation Name: Cuent Addess: Defeed Compensation Unfoeseeable Emegency Distibution Application Social Secuity Numbe: City: State: Zip Code: Contact Phone Numbe: Addess: Employe: Unfoeseeable Emegency To ualify fo an unfoeseeable emegency distibution, you o you beneficiay must expeience a sevee financial hadship that is a esult of an extaodinay and unfoeseeable event beyond you contol that cannot be elieved using funds available fom you checking, savings, stocks, mutual funds, secuities, insuance, othe assets o by ceasing you defeals. Non-appovable events geneally include: u outine monthly expenses u annual tax liability u puchase of a ca u education expenses u matenity leave u loss of ovetime/holiday pay u puchase of a home u elective/cosmetic sugey u auto maintenance u outine medical expenses u elective othodontia u home maintenance u accumulated cedit cad debt that is not due to any events that ae extaodinay and unfoeseeable and beyond you contol Please descibe you o you beneficiay s sevee financial hadship. The sevee financial hadship must be a esult of one of the following: u Illness o accident of you, you spouse, you beneficiay o dependent u Popety loss due to casualty of you, o you beneficiay u Othe simila extaodinay and unfoeseeable event, beyond you o you beneficiay s contol (see Plan Document) Please explain in detail how the sevee financial hadship is a esult of one of the causes listed above: 2

3 Unfoeseeable Emegency (continued) Reason Popety Loss Due To Accident /Casualty Defeed Compensation Unfoeseeable Emegency Distibution Application You must submit documentation to suppot you euest fo an Unfoeseeable Emegency distibution. Please see the examples below fo documentation that may be euied. Note: In most cases, the use of "you" in the following section efes to you, o you beneficiay. Home Repai/ Modification Repai of Pimay Vehicle Due to Accident o Casualty Reuied Documentation If you have insuance: a lette fom you insuance company indicating the amount coveed by insuance and deductible amount owed, o easons fo no coveage If you do not have insuance; a signed statement indicating you do not have insuance (may be included in the explanation on page two of this euest) Detailed epai estimate fom a licensed contacto indicating the specific causes of the damage If you have insuance: a lette fom you insuance company indicating the amount coveed by insuance and deductible amount owed, o easons fo no coveage If you do not have insuance; a signed statement indicating you do not have insuance (may be included in the explanation on page two of this euest) Detailed epai estimate fom a licensed contacto If you have insuance: a lette fom you insuance company indicating the amount coveed by insuance and deductible amount owed, o easons fo no coveage If you do not have insuance; a signed statement indicating you do not have insuance (may be included in the explanation on page two of this euest) Detailed epai estimate fom a licensed mechanic indicating the make and model of the vehicle in need of epais If the esult of an accident, official Police Repot Imminent Foeclosue/ Eviction If foeclosue, lette dated within 60 days fom the motgage company indicating the dolla amount needed to pevent imminent foeclosue o acceleation on you pimay esidence. Must include the popety addess of the loan unde theat of foeclosue If eviction, lette dated within 60 days fom the landlod/leasing agency o cout odeed eviction notice indicating the dolla amount needed to pevent imminent eviction fom you pimay esidence Pimay Vehicle Repossession Lette dated within 60 days fom the lende indicating the dolla amount needed to pevent epossession o sale of you epossessed pimay vehicle Customay Funeal/Buial Expenses Detailed invoice fom a funeal home and/o cemetey that itemizes the cost of funeal expenses fo which you ae esponsible Copies of eceipts, booking infomation (ai/hotel), and othe tavel expenses elated to the funeal and/o buial Medical/Dental/ Pesciption Expenses If you have insuance: Explanation of Benefits foms fom the insuance company indicating insuance coveage (o easons fo no coveage), patient esponsibility, and dates of sevice fo all chages If you do not have insuance: Detailed bills indicating the dates of sevice fo all chages and a signed statement indicating you do not have insuance (may be included in the explanation on page two of this euest) If the pocedue could be consideed cosmetic, a lette fom a medical docto/dentist indicating the easons why the pocedue is medically necessay Fo futue sevices: a pe-teatment estimate indicating insuance coveage and patient esponsibility fo all pocedues that ae to be pefomed and anticipated date of sevice along with a statement fom the povide showing that payment must be made befoe the teatment will be endeed 3 Utility Disconnection of Gas,Electic,Wate, o Heating Oil/ Popane Lette dated within 60 days fom the utility company indicating the dolla amount needed to pevent imminent disconnection of eligible utility sevices at you pimay esidence

4 Unfoeseeable Emegency (continued) Defeed Compensation Unfoeseeable Emegency Distibution Application Legal Fees Signed attoney etaine ageement, and/o Detailed list of costs incued fom the attoney indicating dates of sevice fo all chages Moving Expenses Rental/lease ageement Copies of bills/eceipts fo moving expenses If elated to a divoce o sepaation: copy of one if the following (on file with the cout): Legal Sepaation ageement, initial complaint fo divoce, final divoce decee Child Suppot Lette fom the Child Suppot Enfocement Agency indicating the amount of child suppot in aeas that is owed to you. Involuntay Loss of Income Lette fom you employe indicating you dates of employment and the dates of wok missed that you eceived educed o no pay. The lette must indicate any sick/vacation pay, disability pay, woke s compensation benefits, unemployment benefits, o any othe fom of compensation eceived while out of wok A copy of you last full pay stub indicating egula full pay ate, and if still employed, a cuent pay stub showing educed pay. Documentation to show a minimum of 6 months of pay in the same position, o 1 yea of simila pay If applicable, documentation fom the unemployment office listing when benefits stat and the dolla amount you ae eligible to eceive. If elated to a divoce o sepaation: copy of one of the following (on file with the cout): Legal Sepaation ageement, initial complaint fo divoce, final divoce decee. If fom a pesonal business, lette fom licensed physician indicating dates when you wee medically unable to wok, 1 yea pofit/loss statement, and Schedule C tax filings Items to keep in mind to pevent you euest fom being delayed o denied: u If you unfoeseeable emegency distibution is due to a legal dependent's situation, we will euie a copy of the ualified dependent woksheet to show dependency u Documentation being supplied fom thid paties must be on thid paty s lettehead u The documentation povided must geneally be dated within the pevious 12 months u Sign you application and the tax foms povided (if applicable) u Please allow up to 10 days fo eceipt and eview All Documentation will be eviewed and does not guaantee appoval of you euest. Please note that additional documentation may be euested. What dolla amount ae you euesting?(applications without a stated euest amount cannot be appoved.) Remembe to complete the diect deposit & tax infomation, and sign on the following page e

5 Defeed Compensation Unfoeseeable Emegency Distibution Application Delivey Options Diect Deposit Infomation (if you chose the Diect Deposit option above) If appoved, how would you like you funds to be deliveed? (Please select one option) Check via U.S. Mail Fom date of issuance please allow 5-7 business days fo eceipt Check via Ovenight Delivey A $25.00 fee will be deducted fom you account po ata Diect Deposit Please complete diect deposit infomation below Please Note: If none of the above options ae selected funds will be issued as a check and distibuted via standad mail. Check only one option: Checking Account Savings Account Bank/Cedit Union Name Account Numbe ABA/Routing Numbe (Fist nine digits only) I: / / / / / / / / / / I: Please note: You ABA/Routing Numbe appeas at the bottom of you checks between the makings indicated above. You must include a voided check if you distibution is being sent to you checking account. Bank o Cedit Union Telephone Numbe: ( ) Tax Infomation Note: Diect Deposit is only offeed though membes of the Automated Cleaing House (ACH). If you account listed above is associated with a bokeage fim o investment fim, please confim with them that the Account Numbe and ABA/Routing Numbe ae coect fo Diect Deposit puposes. All distibutions ae subject to fedeal, applicable state and local taxes. Fedeal Income Tax will be withheld fom you payment as euied by the Intenal Revenue Code. Payments will be epoted on a 1099-R fom. Please select one option. (If you do not select an option, we will use the 10% Default withholding as descibed below.) No Taxes withheld: Do not withhold Fedeal Taxes fom my withdawal. I will be liable fo all Fedeal Taxes that may esult fom this withdawal. 10% Default withholding: Incease the withdawal amount to accommodate Fedeal Tax withholding on the taxable potion of my withdawal. I will eceive the appoved amount of my euest (by check o Diect Deposit), and the total withdawal amount will be highe to include Fedeal Tax withholding. Signatue & Authoization I veify that all infomation povided on this application is cuent, complete, and accuate. I veify that my event may not be elieved using funds available fom my checking, savings, stocks, mutual funds, secuities, insuance, othe assets o by ceasing my defeals. I undestand it is my esponsibility to and I agee to maintain the documentation suppoting this unfoeseeable emegency euest. I undestand that these funds may not be olled ove into an IRA, 401, 403(b), o anothe 457 plan. I undestand that if I am still defeing to the Plan, my euest fo unfoeseeable emegency withdawal may be denied. Paticipant s Signatue Date Please MAIL the completed application and suppoting documentation to: NATIONWIDE RETIREMENT SOLUTIONS P O BOX COLUMBUS OH If you pefe, you can FAX the completed application and suppoting documentation to Thank you fo you paticipation in the defeed compensation pogam. If you have any uestions, please call us at