Page 1 of 4 Questions? Call 877-NRS-FORU (877-677-3678) Visit us online Go to nrsforu.om to learn about our produts, servies and more. Important information about our Unforeseeable Emergeny Appliation To apply Call us at 877-NRS- FORU (877-677-3678) for help ompleting your appliation; then fax your ompleted appliation and supporting doumentation to 877-677-4329. We understand you are experiening ertain diffiulties and are onsidering a request for an Unforeseeable Emergeny distribution to withdraw funds from your Deferred Compensation Plan aount. The Internal Revenue Code and Treasury regulations govern the irumstanes in whih funds may be withdrawn. We ve outlined these requirements below. Understanding if you qualify An Unforeseeable Emergeny is a severe finanial hardship to the partiipant or benefiiary that ourred within the last 12 months due to: An illness or aident of the partiipant or benefiiary; or spouse or dependent of the partiipant or benefiiary NOTE: A dependent is defined as an individual who reeives 50% or more of their finanial support from the partiipant or benefiiary, as refleted in tax reporting douments. Medial expenses not overed by insurane or other reimbursements Funeral expenses for a spouse or dependent Loss of the partiipant s or benefiiary s property due to asualty, suh as damage aused by a hurriane or tornado Forelosure or evition from partiipant s or benefiiary s primary residene NOTE: The determination of an unforeseeable emergeny will depend on the fats and irumstanes of eah ase. Regulations do not onsider a planned or voluntary event to be an unforeseen emergeny. Examples may inlude, but not limited to: purhasing a home or automobile, eduation expenses, normal monthly expenses like gas or groeries, eletive surgery, taxes, legal fees/judgments, moving expenses or loss of inome that is not the diret result of an illness or aident would likely not qualify. Also, the regulations state you must exhaust all other means of relief first; then, if approved, we will reimburse the remaining amount. Means of relief may inlude: Insurane or other soures Liquidation of the partiipant s assets, to the extent suh liquidation would not itself ause severe finanial hardship Disontinuing ontributions See reverse side for additional information
Page 2 of 4 Keep in mind If your situation is deemed an Unforeseeable Emergeny, the amount of your withdrawal request annot exeed the urrent value of your aount. Funds may only be withdrawn from pre-tax ontributions (salary redution) and post-tax ontributions. If a portion of your aount is funded by a rollover from a previous retirement plan, you may be eligible to withdraw those funds by ontating Nationwide Retirement Solutions (NRS) at 877- NRS-FORU (877-677-3678). What you need to do To submit an Unforeseeable Emergeny Appliation, please return all material by: Fax: 877-677-4329 P.O. Box Address: Nationwide Retirement Solutions PO Box 182797 Columbus OH 43218-2797 Express Mail Address: Nationwide Retirement Solutions 3400 Southpark Pl Ste A, DSPF-F2 Grove City OH 43123-4856 Please inlude: A ompleted and signed appliation Any supporting doumentation listed on the Unforeseeable Emergeny Cheklist (see page 4 of Important Information doument) What to expet If your unforeseeable emergeny request is approved, funds will be withdrawn from your aount on a prorated basis aross both pre-tax and post-tax money soures, if appliable. Earnings from post-tax ontributions are only onsidered tax-free five years after the first post-tax ontribution to the plan and when you reah age 59 ½. Some mutual funds may impose a short term trade fee. Please read your underlying prospetuses arefully. A deision is typially made within five business days of reeiving all required douments.
Page 3 of 4 Important things to onsider If you urrently have life insurane overage through the plan and hoose to stop your ontributions due to your Unforeseeable Emergeny, your poliy ould lapse due to non-payment. This means your poliy will be anelled and you ll no longer have overage. Please ontat our offie to disuss the options available to ontinue your life insurane overage. If you have money in the Self-direted Brokerage Option and the requested amount exeeds your ore aount balane, you ll need to transfer funds bak to the ore aount before your request an be proessed. Nationwide does not provide tax or legal advie, and federal laws related to these types of aounts are omplex and an hange. Be sure to onsult with your tax advisor or lawyer if you have questions. For help when you need it If you have any questions, please referene the Frequently Asked Questions doument. If you have any additional questions or need more information, ontat our servie enter at 877-NRS-FORU (877-677-3678) Monday through Friday from 8 a.m. to 11 p.m. Eastern time. Nationwide Retirement Solutions, PO Box 182797, Columbus OH 43218-2797 Nationwide Investment Servies Corporation, member FINRA. In Mihigan only - Nationwide Investment Svs. Corporation NRN-0925AO-0914
Page 4 of 4 UNFORESEEABLE EMERGENCY CHECKLIST REASON Illness or Aident: Medial Expenses (Not overed by insurane or other reimbursements) Illness or Aident: Loss of Inome Property Loss Due To Casualty SUPPORTING DOCUMENTATION If you have health insurane: Explanation of Benefits statement from within the past 12 months from the insurane ompany indiating insurane overage (or reasons for no overage), patient responsibility and dates of servie for all harges. If you do not have health insurane: inlude a signed statement indiating that you do not have insurane and the speifi dates of no overage. If you do not have insurane: Detailed bills indiating the medial provider s name & address, date of servie, proedures performed and harges inurred within past 12 months. If medial expenses are for a dependent, inlude a opy of the most reent Federal Inome Tax Return (pages 1 & 2 only) for you, and if married, your spouse. State tax forms are not needed. If the proedure ould be onsidered osmeti, a letter from a medial dotor/dentist indiating the reasons why the proedure is medially neessary. Copy of the Pre-Determination of Benefits, dated or issued within last 60 days, from the insurane provider. A statement from provider showing that payment must be made before treatment will be rendered. If you have a disounted Dental Plan that does not issue Dental Explanation of Benefits statements, please provide opies of the Shedule of Benefits that inlude the proedure ode(s) that math the proedures on the dental pre-treatment estimate. Detailed presription drug history from your pharmay or insurane ompany stating dates mediations were filled, how muh insurane overed, and the dollar amount you are responsible for paying. Letter from your spouse s, primary benefiiary s, or dependent s employer indiating dates of employment and the dates of work missed that there was redued or no pay reeived. This must also indiate any sik/vaation pay, disability pay, worker s ompensation benefits, or any other form of ompensation reeived while out of work. A Loss of Inome Verifiation Form ompleted by your employer. A opy of the most reent Federal Inome Tax Return (pages 1 & 2 only) for you, and if married, your spouse. State tax forms are not needed. A opy of the two most reent pay stubs for you, and if married, your spouse. Doumentation from the Worker s Compensation board or disability board regarding your, your spouse s, primary benefiiary's, or dependent's Worker s Compensation or disability benefits. The doumentation must state the date the benefits began/will begin, the amount of the benefits, and the date benefits will/may end. If your spouse, dependent, or primary benefiiary is self employed, letter from liensed physiian indiating dates when the person was medially unable to work, and 1 year profit/loss statement and Shedule C tax filings. If you have insurane: a letter from your insurane ompany indiating the amount overed by insurane and dedutible amount owed, or reasons for no overage. If you do not have asualty insurane: inlude a signed statement indiating that you do not have insurane and the speifi dates of no overage. Detailed repair estimate from a liensed ontrator or liensed mehani indiating the speifi auses of the damage to your primary residene or primary vehile. Polie report. Letter from the other driver s insurane ompany stating why they are not overing the damages to your primary vehile or the amount they will over. A statement from your automobile lender indiating the amount still owed after the insurane payoff was reeived. Funeral Expenses A opy of the death ertifiate. Doumentation of the relationship to the deeased. Forelosure / Evition (If requested more than one in a 12 month period, ould be subjet to additional review) Extraordinary/Unforeseeable Cirumstane Detailed invoie from a funeral home and or emetery that itemizes osts of funeral/burial expenses in whih you are personally responsible, along with the amount that the deedent's funeral insurane/burial insurane will over. If you are not listed as the responsible party on the bill, inlude a statement on or with the appliation indiating that you are responsible for the expenses. Copies of reeipts, booking information (air/hotel), and other travel expenses related to the funeral and or burial. Address on file mathes the address on the request. If not, pages 1-2 of the 1040 Federal Tax Return and Shedule E (rental property page) are required (you may blak out information that is not neessary to verify the address). Letter from the Mortgage Company or lender's attorney issued from within the past 30 days indiating a dollar amount needed to prevent imminent forelosure, a lear future date due, and full address of property that is under threat of forelosure. Evition: A letter from the Leasing Ageny or a opy of the Court Order Evition issued within the past 30 days stating the dollar amount needed to prevent the evition from your primary residene with the property address that is under threat of evition. Copy of your urrent lease agreement. If a bankrupty has been filed, doumentation showing the mortgage lender has been granted relief from automati stay or ourt order stating dismissal of bankrupty ase. Inlude opies of douments supporting your statement that the irumstanes arose as a result of events beyond the ontrol of you, your spouse, your dependent, or benefiiary.
457 Unforeseeable Emergeny Distribution Frequently Asked Questions How do I submit an appliation for an Unforeseeable Emergeny (UE) Distribution? This appliation is designed to provide information about your finanial emergeny, and to determine if you have other appropriate finanial soures that ould relieve your finanial hardship. Without this information the Plan an not onsider your request. Please fill out the appliation and finanial page ompletely. All appliations remain ative for 30 days from the date of reeipt. Any additional unforeseeable emergeny request beyond 30 days from the date of reeipt requires a new appliation. FOR FASTER SERVICE, please FAX the ompleted appliation and supporting doumentation to: 1-877-677-4329. If you prefer, you an MAIL the ompleted appliation and supporting doumentation to: P.O. BOX ADDRESS: OR EXPRESS MAIL ADDRESS: NATIONWIDE RETIREMENT SOLUTIONS P O BOX 182797 COLUMBUS OH 43218-2797 NATIONWIDE RETIREMENT SOLUTIONS 3400 SOUTHPARK PL STE A, DSPF-F2 GROVE CITY OH 43123-4856 If you have any additional questions regarding the proess or ompletion of this form, please all the ontat enter at 1-877- NRS- FORU (1-877-677-3678). The hours of operation are Monday-Friday 8am 11pm ET. Who may apply for an Unforeseeable Emergeny (UE) Distribution? An atively employed partiipant may apply for a UE. Retired or terminated partiipants, benefiiaries, and alternate payees are not eligible for an unforeseeable emergeny. Please refer to standard distribution. (Partiipants over 70 ½ and still atively employed are eligible for standard distributions from the Plan, and are not eligible for unforeseeable emergeny distributions.) What information and douments are required for the Unforeseeable Emergeny (UE) appliation? In addition to doumentation regarding the speifi irumstanes for whih a UE is requested, partiipants applying for a UE are required to submit: A ompleted and signed appliation. Any supporting doumentation, as listed under the Unforeseeable Emergeny Cheklist page (see page 4 of Important Information doument). Should I ontinue or stop my deferrals? You may hoose to stop deferring into the Plan when applying for a UE distribution. You might want to take some time to reover from the related irumstanes and to replenish your regular savings by temporarily stopping your deferrals. If you stop your deferrals, in order to begin deferring into your aount again; you will need to submit a new partiipation agreement. To do so, please ontat us at 1-877-677-3678. How muh an I withdraw? UE distributions must be limited to the amount reasonably neessary to satisfy the finanial need, but may be inreased for Federal inome taxes on the distribution. What is the proess and how long does it take? Assuming your paper work is omplete and aurate your appliation and supporting doumentation will be proessed within 5 business days. We make every effort to review your request as soon as possible. Is the Unforeseeable Emergeny Distribution a taxable event? Yes. Federal inome tax will be withheld at the rate of 10% unless you elet to have no tax withheld or elet an additional amount of withholding on IRS Form W-4P. IRS Form 1099-R will be issued at the end of the year for tax reporting purposes and sent to you and the Internal Revenue Servie. Where possible, the approved amount will be inreased to inlude the amount for withholding, if aount balane is insuffiient to be grossed up to over federal taxes, taxes will be withheld and the remaining amount will be sent to the partiipant. Please ontat your tax advisor for any questions or onerns. Page 1 of 2 NRN- 0926AO- 0914
457 Unforeseeable Emergeny Distribution Frequently Asked Questions Is this distribution eligible for rollover to another eligible retirement plan or IRA? No. What are the Federal regulations that over UEs? 1.457-6() desribes the rules that apply to UEs () Rules appliable to distributions for unforeseeable emergenies (1) In general. An eligible plan may permit a distribution to a partiipant or benefiiary faed with an unforeseeable emergeny. The distribution must satisfy the requirements of paragraph ()(2) of this setion. (2) Requirements (i) Unforeseeable emergeny defined. An unforeseeable emergeny must be defined in the plan as a severe finanial hardship of the partiipant or benefiiary resulting from an illness or aident of the partiipant or benefiiary, the partiipant s or benefiiary s spouse, or the partiipant s or benefiiary s dependent (as defined in setion 152(a)); loss of the partiipant's or benefiiary s property due to asualty (inluding the need to rebuild a home following damage to a home not otherwise overed by homeowner s insurane, e.g., as a result of a natural disaster); or other similar extraordinary and unforeseeable irumstanes arising as a result of events beyond the ontrol of the partiipant or the benefiiary. For example, the imminent forelosure of or evition from the partiipant's or benefiiary s primary residene may onstitute an unforeseeable emergeny. In addition, the need to pay for medial expenses, inluding non-refundable dedutibles, as well as for the ost of presription drug mediation, may onstitute an unforeseeable emergeny. Finally, the need to pay for the funeral expenses of a spouse or a dependent (as defined in setion 152(a)) may also onstitute an unforeseeable emergeny. Exept as otherwise speifially provided in this paragraph ()(2)(i), the purhase of a home and the payment of ollege tuition are not unforeseeable emergenies under this paragraph ()(2)(i). (ii) Unforeseeable emergeny distribution standard. Whether a partiipant or benefiiary is faed with an unforeseeable emergeny permitting a distribution under this paragraph () is to be determined based on the relevant fats and irumstanes of eah ase, but, in any ase, a distribution on aount of unforeseeable emergeny may not be made to the extent that suh emergeny is or may be relieved through reimbursement or ompensation from insurane or otherwise, by liquidation of the partiipant's assets, to the extent the liquidation of suh assets would not itself ause severe finanial hardship, or by essation of deferrals under the plan. (iii) Distribution neessary to satisfy emergeny need. Distributions beause of an unforeseeable emergeny must be limited to the amount reasonably neessary to satisfy the emergeny need (whih may inlude any amounts neessary to pay any federal, state, or loal inome taxes or penalties reasonably antiipated to result from the distribution). What are the Plan requirements for UEs under the Nationwide Retirement Solutions (NRS) standard 457 plan? The NRS standard 457 plan doument desribes unforeseeable emergenies as follows: (A) Unforeseeable Emergeny. In the event of a Partiipant s unforeseeable emergeny, the Administrative Servies Provider may make a distribution to a Partiipant who has not inurred a Severane from Employment. An unforeseeable emergeny is a severe finanial hardship of a Partiipant or Benefiiary resulting from: (1) illness or aident of the Partiipant, the Partiipant s Benefiiary, or the Partiipant s spouse or dependent (as defined in Code 152, and, for taxable years beginning on or after January 1, 2005, without regard to Code 152(b)(1), (b)(2), and (d)(1)(b)); (2) loss of the Partiipant s or Benefiiary s property due to asualty; (3) the need to pay for the funeral expenses of the Partiipant s spouse or dependent (as defined in Code 152, and, for taxable years beginning on or after January 1, 2005, without regard to Code 152(b)(1), (b)(2), and (d)(1)(b)); or (4) other similar extraordinary and unforeseeable irumstanes arising from events beyond the Partiipant s or Benefiiary s ontrol. The Administrative Servies Provider will not pay the Partiipant or the Benefiiary more than the amount reasonably neessary to satisfy the emergeny need, whih may inlude amounts neessary to pay taxes or penalties on the distribution. The Administrative Servies Provider will not make payment to the extent the Partiipant or Benefiiary may relieve the finanial hardship by essation of deferrals under the Plan, through insurane or other reimbursement, or by liquidation of the individual s assets to the extent suh liquidation would not ause severe finanial hardship. The Partiipant s Benefiiary is a person who a Partiipant designates as a primary benefiiary and who is or may beome entitled to a Partiipant s Plan aount upon the Partiipant s death. A Partiipant s unforeseeable emergeny event inludes a severe finanial hardship of the partiipant s primary Benefiiary under the Plan, that would onstitute an emergeny event if it ourred with respet to the partiipant s spouse or dependent as defined under Code 152. How do I appeal an unfavorable deision? An unfavorable deision may be appealed within 30 alendar days within notifiation of denial by sending a written request and any additional supporting doumentation that may be relevant for the appeal. You will be notified of the final outome of the appeal. One the appeal has been reviewed and a determination has been made that deision is final and will not be subjet to further appeal. Nationwide Investment Servies Corporation, member FINRA. In Mihigan only - Nationwide Investment Svs. Corporation Page 2 of 2 NRN- 0926AO- 0914
Nationwide Retirement Solutions 457 Unforeseeable Emergeny Distribution Form Personal Information Plan Name: Partiipant Name: SSN #: Mailing Address: City, State, & Zip Code: Date of Birth: Phone Number: Email Address: How would you like to be ontated if additional information is required? Telephone Email Unforeseeable Emergeny Details (Required) Was the severe finanial hardship a result of some unforeseeable irumstane arising as a result of events beyond the ontrol of you, your spouse, dependent or primary benefiiary? Yes No If no, STOP, do not submit your request. it does not qualify as an unforeseeable emergeny. If yes, please provide a detailed explanation of the unforeseeable emergeny that has aused you, your spouse, your dependent or your primary benefiiary a severe and unforeseeable finanial hardship. Please be as detailed as you an, inluding names and dates. Attah extra sheets if needed. Date(s) unforeseeable emergeny ourred NOTE: Cirumstanes over 12 months from the date of appliation will not be onsidered for unforeseeable emergeny distributions. DC-3106 (11/2015) For help, please all 877-677-3678 www.nrsforu.om 1
Finanial Position Aknowledgement THIS ACKNOWLEDGEMENT IS REQUIRED TO BEGIN THE REVIEW PROCESS I attest that the unforeseeable emergeny has aused a severe and unforeseeable finanial hardship to me, my spouse, dependent, or primary benefiiary that annot be met through any other means, inluding the following: 1. The reasonable liquidation of funds in heking and/or savings aounts, provided the liquidation would not itself ause an immediate and heavy finanial need, 2. The reasonable liquidation of funds in investment aounts, IRA s, and/or insurane poliy ash values, provided the liquidation would not itself ause an immediate and heavy finanial need, 3. The reasonable liquidation of nonessential assets (i.e. rental/vaation properties, RV s, boats, or other), provided the liquidation would not itself ause an immediate and heavy finanial need, 4. The anellation of eletive deferrals under the 457 Deferred Compensation Plan, 5. Other urrently available distributions or nontaxable loans from other plans maintained by my employer or any other employer, 6. Borrowing from ommerial soures on reasonable ommerial terms in an amount suffiient to satisfy the need. I ertify that all of the information provided in this appliation is true, omplete and aurate. Print Name: Signature: Date: Distribution Amount Distributions due to unforeseeable emergenies are only permitted in the amount neessary to satisfy the finanial need after reimbursement by insurane or other soures. Please attah required doumentation to support the requested amount. This distribution may be taxable. Amount Requested $ OR Maximum Amount Allowed Stopping your deferrals may help alleviate your finanial need. If you would like to stop your deferrals please ontat ustomer servie at 1-877-677-3678. Seleting to stop ontributions will require the ompletion of a new partiipation agreement to restart your ontributions to the deferred ompensation plan. 2 DC-3106 (11/2015) For help, please all 877-677-3678 www.nrsforu.om
Payment Method Send hek by first lass mail to my address of reord. Allow 5 to 10 business days from proess date for delivery. (Default option, if no other option is seleted) Send hek overnight at my expense to my address of reord. I understand there is an additional $25.00 fee that will be deduted from my aount. P.O. Box addresses are not eligible for overnight delivery and Saturday delivery may not be available in your area. Allow 2 to 4 business days from proess date for delivery. ACH Instrutions on File Send funds to my bank aount that NRS has on file. Diret Deposit by ACH: Chek only one option: Cheking Aount Savings Aount Bank/Credit Union Name ( ) Bank/Credit Union Phone Number ABA (Routing) Number* (first nine digits only) Aount Number Note: Diret Deposit is only offered through members of the Automati Clearing House (ACH). We annot aept a deposit slip for banking numbers. If ACH information is not ompleted orretly a hek will be sent to your address on file. Is this aount assoiated with a brokerage firm or other investment firm? If yes, have you onfirmed that the ABA and aount numbers are orret? Yes No Yes No I hereby authorize NRS to initiate automati deposits to my aount at the finanial institution named above. In the event an error is made, I authorize NRS to make a withdrawal from this aount. Further, I agree not to hold NRS responsible for any delay or loss of funds due to inorret or inomplete information supplied by me or by my finanial institution or due to an error on the part of my finanial institution in depositing funds to my aount. This agreement will remain in effet until NRS reeives a written notie of anellation from me or my finanial institution, or until I submit a new diret deposit authorization form to NRS. In the event this diret deposit authorization form is inomplete or ontains inorret information, I understand a hek will be issued to my address of reord. Tax Withholding Federal Tax: Please selet one option, if no option is seleted, NRS will use a default rate of 10% federal tax withholding. Inreases the distribution amount to aommodate federal tax withholding on the taxable portion on my distribution. I will reeive the approved amount of my request (by hek or diret deposit), and the total distribution amount will be inreased to inlude federal tax withholdings. NRS will use a default withholding rate of 10%. If aount balane is insuffiient to aommodate federal taxes, 100% of the aount balane will be proessed an 10% federal taxes will be withheld. The remaining balane will be sent (by hek or diret deposit) to the member. Do not withhold federal tax from my distribution. I will be liable for all federal taxes that may result from this distribution. State Tax: State taxes will be automatially withheld if you are a resident in a state that mandates state inome tax withholding. If you would like to adjust your state taxes, please omplete and attah a state tax withholding form. These forms an be obtained from the State web site, NRS does not supply these forms. DC-3106 (11/2015) For help, please all 877-677-3678 www.nrsforu.om 3
Certifiation Under penalties of perjury, I ertify that: 1. The number shown on this form is my orret taxpayer identifiation number (or I am waiting for a number to be issued to me), and 2. I am not subjet to bakup withholding beause: (a) I am exempt from bakup withholding, or (b) I have not been notified by the Internal Revenue Servie (IRS) that I am subjet to bakup withholding as a result of a failure to report all interest or dividends, or () the IRS has notified me that I am no longer subjet to bakup withholding, and 3. I am a U.S. itizen or other U.S. person. 4. The FATCA ode entered on this form (if any) indiating that the payee is exempt from FATCA reporting is orret. Authorization I onsent to a distribution as eleted above. I understand that the terms of the Plan doument will ontrol the amount and timing of any payment from the plan. I further aknowledge that this distribution is not eligible for rollover to another retirement plan or IRA. As required by law, and under the penalty of perjury, I ertify the Soial Seurity Number (Taxpayer Identifiation Number) and information I have provided is orret. I am not subjet to bakup withholding beause: (a) I am exempt from bakup withholding, or (b) I have not been notified by the Internal Revenue Servie (IRS) that I am subjet to bakup withholding as a result of a failure to report all interest or dividends, or () the IRS has notified me that I am no longer subjet to bakup withholding, and I am a U.S. itizen or other U.S. person. Print Name: Signature: Date: Form Return By mail: Nationwide Retirement Solutions PO Box 182797 Columbus, OH 43218-2797 OR By fax: 877-677-4329 Express mail address: Nationwide Retirement Solutions 3400 Southpark Plae, Suite A DSPF-F2 Grove City, OH 43123-4856 4 DC-3106 (11/2015) For help, please all 877-677-3678 www.nrsforu.om