ࡱ> jmi #bjbjޤ \tƴƴ=====$aaaP5Ta&aaaa+/D=&?&?&?&?&?&?&>(*h?&=!@^!!?&==aa,T&}$}$}$!R=a=a=&}$!=&}$}$}$a Fa"}$)&j&0&}$H+ #rH+}$H+=}$vm T}$ D!?&?&}$&!!!!H+ : Emergency Withdrawal Effective Suspension Date  FORMCHECKBOX  FORMCHECKBOX / FORMCHECKBOX  FORMCHECKBOX / FORMCHECKBOX  FORMCHECKBOX  Deferred Comp Use Only Section 1 Participant Information (Please PRINT NAME EXACTLY as reported to your payroll office) Name (First, MI, Last) ___________________________________________________________ SSN* _______________________ Street Address: ______________________________________________________  FORMCHECKBOX  Male  FORMCHECKBOX  Female City: _________________________________________ State: _____ Zip: _____________ Date of Birth: _____ / _____ / _____ Phone Numbers: Home (______)______________ Work (______)_________________Email Address: _______________________ Please check if this a  FORMCHECKBOX  Name Change  FORMCHECKBOX  Address Change Do you have an outstanding Deferred Compensation loan?  FORMCHECKBOX NO  FORMCHECKBOX YES *Your disclosure of your social security number or taxpayer identification number is required. Section 112.215 F.S. authorizes the creation of the State of Florida Deferred Compensation Plan, which is intended to qualify for tax deferral pursuant to 26 USC 457. Use of the identifying numbers is mandated by 26 USC 6109. Your social security number or taxpayer identification number will be used as an identifying number for purposes of federal tax law. Section 2 - Unforeseeable Emergency Categories Please check one or more of the following guidelines that pertains to you, your spouse or your dependent  FORMCHECKBOX Out of Pocket Medical, or Funeral Expenses  FORMCHECKBOX Loss of Salary Due to Termination, Illness, or Accident  FORMCHECKBOX Loss of Child Support Payments to Support Dependant Child  FORMCHECKBOX Entry of a Minor Relative, or Ward into the Participants Household  FORMCHECKBOX Loss of Property Due to a Casualty  FORMCHECKBOX Foreclosure or Eviction on Primary Residence  FORMCHECKBOX  Other Sudden and Unexpected Event pursuant to Section 1.38 or 5.05 of Form DFS-J3-1176 Section 3 - Investment Provider (IP)Information Which IP(s) do you want to withdraw from?  FORMCHECKBOX Nationwide  FORMCHECKBOX VOYA  FORMCHECKBOX VALIC  FORMCHECKBOX Great West Retirement  FORMCHECKBOX T Rowe Price _______ _______ _______ Gross amount to be withdrawn  FORMCHECKBOX  Full  FORMCHECKBOX  Partial $____________ .00 Section 4 Federal Income Tax Information Complete attached W4 Form and return with completed UE Withdrawal Form. NOTICE: Unforeseeable Emergency withdrawals are paid in a lump sum. All lump sum payments are paid by the investment provider(s) and taxed at 10% unless otherwise indicated above. A request for an Unforeseeable Emergency Withdrawal will result in all contributions being suspended until reinstated by the participant. Date to restart your contribution: _____ / _____ / _____ By signing this application, I hereby acknowledge the following: I have exhausted all other sources available to pay the financial hardship described and the amount I requested is only the amount that I reasonably require to satisfy the emergency need. My financial hardship cannot be relieved through reimbursement or compensation by insurance or otherwise; a loan or a financial hardship withdrawal from a 401(k) plan (if available); by liquidation of my assets, to the extent such liquidation would not itself cause severe financial hardship; or by cessation of deferrals under the Plan. I have attached documentation supporting this request for an emergency withdrawal. I understand that these funds are taxable to me in the year that I receive them. Emergency Withdrawals are not an eligible Rollover distribution. __________________________________________________________________ Participant Signature Date This request is: APPROVED DENIED ________________________________________ Authorized Deferred Compensation Signature Date Please fill out completely. Monthly Income Participants Net Salary $_________________ (attach a copy of current earnings statement) Spouses Net Salary __________________ (attach a copy of current earnings statement) Investment Income __________________ (Real Estate, Stocks, Bonds, etc.) Other Income __________________ Child Support __________________ Miscellaneous __________________ Total Monthly Income $_________________ Monthly Expenses (Not Payroll Deducted) Rent or Mortgage $__________________ Automobile(s) ___________________ Utilities ___________________ Telephone ___________________ Loans ___________________ Credit/Charge Cards ___________________ ________________ ___________________ ________________ ___________________ ________________ ___________________ Insurance ___________________ ________________ ___________________ ________________ ___________________ Groceries ___________________ Gasoline ___________________ Child Care or Support ___________________ Miscellaneous ___________________ ________________ ___________________ ________________ ___________________ Total Monthly Expenses $_________________ Net Overage/Shortage $ _________________ Assets Cash: Checking Account $__________________ Savings Account __________________ Investments: 403(B)/401/IRA/SEP _________________ Stocks ___________________ Bonds ___________________ Mutual Funds ___________________ (excluding Deferred Compensation) Precious Metals ___________________ (gold, silver, etc.) Real Estate _____________________ (current market value) Other Investments ___________________ Other Assets Automobile ___________________ (current market value) Other: _____________________ __________________ _____________________ Total Assets $__________________ Liabilities Home Mortgage $__________________ Mortgage on other ___________________ properties Personal Notes ___________________ ________________ ___________________ ________________ ___________________ Credit/Charge Cards ___________________ ________________ ___________________ Automobile Loan(s) ___________________ Other Debts ___________________ ________________ ___________________ Total Liabilities $__________________ * Income and/or expenses may vary from month to month, therefore, please indicate the estimated average.     Department of Financial Services Division of Treasury Bureau of Deferred Compensation State of Florida Deferred Compensation Plan Income Statement Financial Position Statement Department of Financial Services Division of Treasury Bureau of Deferred Compensation State of Florida Deferred Compensation Plan Request for an Unforeseeable DFS-J3-1171 (REV 11/06) PG. 2 DFS-J3-1171 (rev. 03/15) Adopted in Rule 69C-6.003, F.A.C. Department of Financial Services Division of Treasury Bureau of Deferred Compensation State of Florida Deferred Compensation Plan Income Statement DFS-J3-1171 (rev. 03/15) PG. 2 Adopted in Rule 69C-6.003, F.A.C. /01?@ACQRSTUVdefhvwxyz{ʻwhYjhl2CJUaJj\hl2CJUaJjhl2CJUaJjthl2CJUaJjhl2CJUaJjhl2CJUaJh}{h CJaJjh}{hl2CJUaJ h 5hV!h 5CJaJh+h 5CJaJh 5;CJaJhs\h 5;CJaJ" ' )   r )$$d%d&d'dNOPQa$gd'n&$d%d&d'dNOPQgd'ngd $a$gd $a$gd  ! 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