Sacramento Metropolitan Fire District Unforeseeable Emergency Application

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1 Explanation & About Reuests for Emergencies As your Deferred Compensation Plan Administrator, we are pleased to provide you with information regarding your reuest for an Emergency. An Emergency is described in the regulations issued under Section 457 of the Internal Revenue Code as: "... a severe financial hardship of the participant or beneficiary resulting from an illness or accident of the participant or beneficiary, the participant's or beneficiary's spouse, or the participant's or beneficiary's dependent... ; loss of the participant's or beneficiary's property due to casualty (including the need to rebuild a home following damage to a home not otherwise covered by homeowner's insurance, e.g., as a result of a natural disaster); or other similar extraordinary and unforeseeable circumstances arising as a result of events beyond the control of the participant or the beneficiary. For example, the imminent foreclosure of or eviction from the participant's or beneficiary's primary residence may constitute an unforeseeable emergency. In addition, the need to pay for medical expenses, including non-refundable deductibles, as well as for the cost of prescription drug medication, may constitute an unforeseeable emergency... Except as otherwise specifically provided in this paragraph... the purchase of a home and the payment of college tuition are not unforeseeable emergencies under this paragraph Whether a participant or beneficiary is faced with an unforeseeable emergency permitting a distribution... is to be determined based on the relevant facts and circumstances of each case, but, in any case, a distribution on account of unforeseeable emergency may not be made to the extent that such emergency is or may be relieved through reimbursement or compensation from insurance or otherwise, by liuidation of the participant's assets, to the extent the liuidation of such assets would not itself cause severe financial hardship, or by cessation of deferrals under the plan.... Distributions because of an unforeseeable emergency must be limited to the amount reasonably necessary to satisfy the emergency need (which may include any amounts necessary to pay any federal, state, or local income taxes or penalties reasonably anticipated to result from the distribution). If you feel that you may ualify for an Emergency, please complete the attached application and the W-4P Federal Tax Withholding Form and mail them to our office. Please note that the amount you reuest for a withdrawal cannot exceed the current value of your account. If your reuest is approved, all funds will be withdrawn on a pro-rated basis across all fund options, according to your allocation percentages. Some mutual funds may impose a short term trade fee. Please read the underlying prospectuses carefully. Please return the completed application and the attached W-4P to: NATIONWIDE RETIREMENT SOLUTIONS P O BOX COLUMBUS OH If you reuire assistance with the completion of the attached forms or have any uestions, please call us at Nationwide Retirement Solutions P.O. Box Columbus, Ohio

2 W-4P Federal Tax Form Instruction Sheet PURPOSE OF FORM: The purpose of the W-4P Form is to provide Nationwide Retirement Solutions with the federal tax information necessary to process your payout. PLEASE NOTE: We do not reuire that you complete the Personal Allowances Worksheet or the Multiple Pensions/More Than One Income Worksheet. However, we do reuire that you complete the Withholding Certificate for Pension or Annuity Payments Section as indicated below. INFORMATION REQUIRED: (Please print or type all information) Name & Address : Name - First, Middle, Last Your Social Security Number Your Home Address - include apartment number or rural route if applicable City, State and Zip Code Tax : 1. Place an X in the box if you elect not to have income taxes withheld 2. Indicate the Number of Allowances and place an X in the box indicating your martial status. 3. Indicate any additional federal tax amount you want withheld from each annuity check. Sign and date the W-4P Form and attach it to your Emergency application. Return both forms to Nationwide Retirement Solutions, PO Box , Columbus OH

3 Participant Participant Name: Current Address: Sacramento Metropolitan Fire District Social Security Number: City: State: Zip Code: Contact Phone Number: Address: Employer Name: Sacramento Metropolitan Fire District Employer Number: 0090 Emergency To ualify for an unforeseeable emergency, you must experience an event beyond your control that cannot be relieved using funds available from your checking, savings, stocks, mutual funds, securities, insurance, other assets or by ceasing your deferrals. Non-approvable events include: u routine monthly expenses u annual tax liability u purchase of a car u education expenses u routine maternity leave u loss of overtime/holiday pay u purchase of a home u elective/cosmetic surgery u routine auto maintenance u routine medical expenses u elective orthodontia u routine home maintenance u divorce-related expenses u funeral expenses for family members NOTE: THIS LIST IS NOT EXHAUSTIVE. 1. Please select the reason for your unforeseeable emergency reuest from the following list. If your reason is not listed on the checklist please add your reason using the "other" box at the end of the list. Please realize you will be reuired to submit documentation to support your reuest. Reason Reuired Documentation Auto Accident Letter from the insurance company indicating a reason for no coverage or deductible amount owed for the repair of your primary vehicle Detailed repair estimate Police report signed by an officer Auto Repair Detailed repair estimate for your primary automobile. Please include a letter from the mechanic explaining why the repairs are not a result of normal wear and tear.this must indicate the make, model, and mileage of the automobile in need of repair. Car Repossession Letter from the auto loan company indicating a dollar amount needed to prevent repossession of your primary automobile Child Support Letter from the Child Support Enforcement Agency indicating amount of child support in arrears that is owed to you. Please note, child support payments that you owe do not ualify Foreclosure/Eviction Letter from the mortgage company indicating a dollar amount needed to prevent foreclosure or acceleration on your primary residence. Letter from the leasing agency or court ordered eviction notice indicating a dollar amount needed to prevent eviction of your primary residence Home Repair/ Detailed repair estimate for damages to your primary residence. Please include Modification a letter from the contractor explaining why the repairs are not a result of normal wear and tear Letter from the insurance company indicating a reason for no coverage If due to medical reasons, letter from physician stating that repairs are medically necessary If covered by insurance, letter from the insurance company indicating deductible amount owed for the repairs

4 Emergency (continued) Involuntary Last full pay stub indicating regular full pay rate Loss of Income Letter from employer indicating dates of employment and UNPAID dates of work missed due to involuntary reasons. This must indicate any sick pay, vacation pay, workers compensation, unemployment benefits or any other form of compensation received while out of work. A two-year pay history must be documented with previous years W-2 forms Legal Fees Signed attorney retainer agreement - this must be for reasons beyond your control. Please note, costs related to a foreseeable event such as Driving Under the Influence (DUI)cannot be approved. Medical/Dental Explanation of benefits forms for all medical bills, or copy(s) of actual bills stating what was not covered by insurance. If no insurance, you will need a statement indicating no medical insurance. Utility Disconnection Other Letter from the utility company indicating a dollar amount needed to prevent disconnection. Items to keep in mind to prevent your reuest from being delayed: u If you have filed bankruptcy - a discharge of debtor will be reuired for any emergency that you are reuesting. u If your unforeseeable emergency is due to a legal dependent's situation, we will reuire a copy of your Federal income tax returns to show dependency. u Documentation must be on company letterhead u The documentation provided must be dated within the previous 12 months u Sign your application and the tax forms provided (if applicable) u Please allow up to 10 days for receipt and review All Documentation will be reviewed and does not guarantee approval of your reuest. Please note that additional documentation may be reuested. 2. Please describe in detail the facts that led to your unforeseeable emergency withdrawal reuest (attach an additional sheet if necessary): 3. What dollar amount are you reuesting?(applications without a stated reuest amount cannot be approved.) Remember to sign and date the form on the next page.

5 Tax All distributions are subject to federal, applicable state and local taxes. Federal Income Tax will be withheld from your payment as reuired by the Internal Revenue Code. Payments will be reported on a 1099R form. Please select the method to handle your tax withholding: r Use the default rate of 10% for Federal Taxes (unless otherwise directed with this form or an attached W-4P, all unforeseeable emergency withdrawals will use a default rate of 10% for Federal Taxes) r Please use the withholding I designated on the attached W-4P form r Do not withhold Federal taxes from my withdrawal. I will be liable for all Federal taxes, including penalties, that may result from this withdrawal Certification Signature & Authorization Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and 2. I am not subject to back up withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and 3. I am a U.S. citizen or other U.S. person. I verify that all information provided on this application is current, complete, and accurate. I verify that my event may not be relieved using funds available from my checking, savings, stocks, mutual funds, securities, insurance, other assets or by ceasing my deferrals. I understand it is my responsibility to and I agree to maintain the documentation supporting this unforeseeable emergency reuest. I understand that these funds may not be rolled over into an IRA, 401, 403(b), or another 457 plan. The Internal Revenue Service does not reuire your consent to any provision of this document other than the certifications reuired to avoid backup withholding. Participant s Signature Date Thank you for your participation in the deferred compensation program. If you have any uestions, please call us at Nationwide Retirement Solutions PO Box Columbus, OH