457 Plan Unforeseeable Emergency Withdrawal Request Fax: 1-888-310-6019 www.copera.org COLORADO PERA 457Plan After you have read all of the following information, complete the 457 Plan Unforeseeable Emergency Withdrawal Request form and mail it to the address at the top of the form with photocopies of the documentation described on the back of the form. Applications received without the requested supporting documentation will not be considered for approval. You may take an unforeseeable emergency withdrawal of your Colorado PERA 457 Plan contributions if you prove one of the following reasons: An illness or accident involving you; your beneficiary; your spouse or your beneficiary s spouse; or your dependent or beneficiary s dependent. Loss of your or your 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, such as the result of a natural disaster). The imminent foreclosure of or eviction from your primary residence or your beneficiary s primary residence. To pay for medical expenses for you; your beneficiary; your spouse or your beneficiary s spouse; or your dependent or beneficiary s dependent, including nonrefundable deductibles, as well as the cost of prescription drug medication. To pay for funeral expenses of your spouse; your beneficiary; your beneficiary s spouse; your dependent or your beneficiary s dependent for taxable years beginning on or after January 1, 2005. Payment may not be made to the extent that the cost of the unforeseeable emergency is or may be relieved: Through reimbursement or compensation by insurance or otherwise; By liquidation of the assets in your account, to the extent the liquidation of such assets would not itself cause severe financial hardship; or By stopping deferrals to the PERA 457 Plan. (You are required to stop deferrals to the Plan for six months following your unforeseeable emergency withdrawal.) You are not eligible for a unforeseeable emergency withdrawal if: Your account balance is greater than $1,132, you are eligible for a loan in the PERA 457 Plan or 401(k) Plan (if applicable), and taking a loan would not itself cause a severe financial hardship. You are age 70½ or older. (You are eligible for a withdrawal of your PERA 457 account.) You made a tax-deferred rollover to your PERA 457 account. (You may withdraw a rollover.) You have terminated employment, including retirement. (You are eligible for a withdrawal of your PERA 457 account.) If you are eligible for one of the above types of withdrawals, contact by calling 1-800-759-7372 and selecting the PERAPlus option. You may also access the 457 Plan website through www.copera.org or by logging into your account with your User ID and password and clicking the PERAPlus 457 Account Access link. Taxation of Unforeseeable Emergency Withdrawal Federal law does not require federal income tax to be withheld on an unforeseeable emergency withdrawal. Unless you elect otherwise, 10 percent will be withheld. Your withdrawal is subject to normal income tax provisions. A 10 percent IRS early withdrawal penalty may apply if the funds withdrawn were previously rolled over from a qualified plan, other than a 457 Plan. Because you may owe federal and state income taxes, you may request that your unforeseeable emergency withdrawal be increased ( grossed up ) to include all of the income taxes and penalties that you reasonably anticipate you will have to pay. There may be additional IRS penalties if you do not have enough taxes withheld. Distributions from the 457 Roth account are tax free as long as the account has been in existence for at least five years and you are at least age 59½, at least age 70½ and still employed, or disabled. 18/9 (REV 11-15)
Processing The unforeseeable emergency withdrawal will be processed for the amount available based on the documentation you provide. If your request for a unforeseeable emergency withdrawal is approved, a check will be mailed to you as soon as possible after the date of the approval. Applications should be mailed to the following address: There is an overnight delivery option for your unforeseeable emergency withdrawal. If you choose to have your withdrawal mailed using this option, you will be assessed at $20 non-refundable fee, which will be deducted from your PERA 457 account. Your overnight delivery unforeseeable emergency withdrawal cannot be sent to a PO box. Overnight applications should be sent to the following address: 30 Braintree Hill Office Park Braintree, MA 02184 This form provides information about PERA s 457 Plan. Your rights, benefits, and obligations as a PERA member are governed by Title 24, Article 51 of the Colorado Revised Statutes, the Rules of the Colorado Public Employees Retirement Association, and The PERA Deferred Compensation Plan document, which take precedence over any interpretations in this form.
457 Plan Unforeseeable Emergency Withdrawal Request COLORADO PERA Fax: 1-888-310-6019 457Plan Complete this form and mail it to at the address above along with the documentation requested (as described on the last page of this form). You may be asked for additional information, if needed, to approve your request. Member SSN Name Last First M.I. Telephone ( ) Email Address Address Street City State ZIP Code Withdrawal and Withholding Information Pre-tax 457 account: Money is contributed to the Plan before taxes are paid. 457 Roth account: Money is contributed to the Plan after taxes are paid. Process an unforeseeable emergency withdrawal in the amount of $ from my pre-tax account. Process an unforeseeable emergency withdrawal in the amount of $ from my Roth (tax-paid) account. If the amount requested is not entirely available from the account you chose above, but funds are available in the other account, Voya will process the difference from the other account. My unforeseeable emergency is due to the following circumstance (check one): q Illness q Loss of property due to casualty q Payment necessary to prevent eviction or foreclosure q Medical expenses q Funeral expenses Please indicate your federal withholding option: q 10% q Other (indicate dollar amount): $ Please indicate your state withholding option: q 10% q Other (indicate dollar amount): $ for I understand that the gross amount of the unforeseeable emergency withdrawal will be calculated such that, after withholding taxes, the net amount will be as close to the amount approved as necessary to meet my unforeseeable emergency. State Mailing Options Choose how you would like to receive your unforeseeable emergency withdrawal check: q First-class mail q Overnight delivery ($20 fee will be deducted from your PERA 457 account) continued on next page 18/9 (REV 11-15)
Authorization By signing this request, I hereby acknowledge the following: I have exhausted all other sources available to pay the unforeseeable emergency described on the previous page and the amount I requested is only the amount that I reasonably require to satisfy my unforeseeable emergency need. My unforeseeable emergency cannot be relieved: Through reimbursement or compensation by insurance or otherwise; By a loan from the PERA 457 Plan or PERA 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 into the Plan. I have attached documentation supporting this request for an unforeseeable emergency withdrawal. I understand that these funds are taxable to me in the year that I receive them. This withdrawal is not an eligible rollover distribution. Distributions from the 457 Roth account are tax free as long as the account has been in existence for at least five years and you are at least age 59½, at least age 70½ and still employed, or disabled. Please see the Special Tax Notice for additional information. I certify, under penalty of perjury, that to the best of my knowledge and belief the information provided on this form, including the Social Security Number or Taxpayer Identification Number, is accurate and complete. I understand that I may be subject to civil and criminal liability for any false statement on this form or any papers attached or related to this form. In addition I will be precluded from making salary deferral contributions for the six-month period following my unforeseeable emergency distribution and I will not receive any employer match (if applicable). Sign Here Signature of Participant Date Please return your completed form with appropriate documentation to the address at the top of the previous page. continued on next page 11/02/2015 CO650303HARDSHN
Documentation Attach copies of any documents that will substantiate both the nature and the amount of the severe financial hardship caused by an unforeseeable emergency. These copies will not be returned; therefore you should not send originals. Reason Illness or medical expenses for you; your beneficiary; your spouse or your beneficiary s spouse; or your dependent or beneficiary s dependent Major property loss due to casualty To prevent eviction from primary residence To prevent foreclosure on primary residence Funeral expenses for your spouse; your beneficiary; your beneficiary s spouse; or your dependent or your beneficiary s dependent Required Documentation (including information that must be reflected on documentation) q All documentation must be dated within the past 12 months. q Eligibility of benefits statement showing amount owed by participant, beneficiary, participant s or beneficiary s spouse, or the participant or beneficiary s dependent, copies of prescription drug bills, or other medical expense statement. If individual does not have insurance they must state so. q Proof of marriage or dependency (i.e., copy of first page and signature page of participants federal income tax return). q A separate written statement indicating that you do not have dental coverage for dental expenses if the request is for dental expenses. q Repair estimate and insurance coverage limit statement in participant s or beneficiary s name dated within the last six months. Repair estimate must be on company letterhead, signed by representative of company, and indicate address of property. If not on company letterhead, signature of representative must be notarized. Insurance statement must indicate address of property, whether the damage was due to casualty, and the nature of the casualty (i.e., fire, flood, wind, etc.). q If you are uninsured, a separate written statement stating that you are uninsured. q If your address on record is a PO Box, proof of residency, such as a utility bill, dated within the past 60 days. q All documentation must be dated within the past 60 days. q Notice from landlord on company letterhead, signed by a representative of the company, indicating property location, amount owed, and a future eviction date. If not on company letterhead, signature of landlord must be notarized. OR q Court notice signed by a judge indicating a future eviction date. q If your address on record is a PO Box, proof of residency, such as a utility bill. q All documentation must be dated within the past 60 days. q Foreclosure notice on official company letterhead from lender indicating property location, amount owed, and a future foreclosure date if the payment is not received in full. q All documentation must be received by Voya before the payment due date expires. OR q Court notice signed by a judge indicating a future eviction date. q If your address on record is a PO Box, proof of residency, such as a utility bill. q All documentation must be dated within the past 12 months. q Funeral home invoice with the name of the participant or beneficiary as the responsible party for payment of the invoice.