Montgomery County Unforeseen Emergency Withdrawal Form
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5Montgomery County
Unforeseen Emergency Withdrawal Form
When submitting this form, Supporting Documentation must be attached. Please type or print
Social Security Number
Last Name
First Name
Middle Initial
Mailing Address
City
State
Zip
Birth Date
Home Telephone
Office Telephone
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1. My Financial hardship is due to the following circumstances (you must submit the requested
documentation):
Sudden and unexpected illness or accident not reimbursed by insurance.
Medical expenses not reimbursed by insurance.
Residential Repair/Loss of property due to a casualty event not reimbursed by insurance.
Prevention of foreclosure or eviction from a primary residence.
Funeral/burial expenses for an immediate family member.
Other similar extraordinary and unforeseeable circumstances arising as a result of events beyond my
control.(If this box is checked please forward this form along with supporting documentation directly to the
County at the address listed below on page 2)
Explanation (
If more space is needed, attach additional pages): __________________________________________
__________________________________________________________________________________________________
_________________________________________________________________________________________
2. I request a withdrawal in the amount of $_______________.
The required documentation of my circumstances and actual hardship, totaling $________ is attached.
Please list your actual hardship expenses. You may request an amount up to 30% greater than the total need
supported by the documentation that you are supplying to cover any taxes or penalties associated with this
withdrawal.
Notice of Withholdings: Please read this section carefully.
The Unforeseen Emergency distribution you receive from the Deferred Compensation Plan is a taxable distribution
subject to Federal Income Tax withholding unless you elect not to have withholding apply. If you elect not to have
withholding apply, please check the box in the Withholding Election section below. Please note that you may also be
subject to tax penalties if your withholding/estimated tax payments are not sufficient. If an election is NOT made, taxes
will be withheld at the rate of 10%.
Withholding Election (Tax is withheld at the rate of 10%)
I
Do
Do Not - want Federal Income Tax Withheld.
Delivery Method:
Electronic Funds Trasnfer (EFT)
EFT is already set up on account.
Allow 3 business days.
Set up EFT to bank or credit union account:
Allow 13-16 business days (includes verification, set –up and transaction processing).
Checking
Provide account information or attach voided check.
Savings
Provide account information or attach deposit slip.
Bank Routing Number:______________________________________________________________________
Bank Name:_______________________________________________________________________________
Checking/Savings Account Number:____________________________________________________________
Checking/Savings Account Owner Name:________________________________________________________
Check
Check sent to mailing address.
Default if no choice indicated. Allow 7 business days.
Check sent by UPS delivery.
A fee of $25 will be deducted from your account. Allow 2 business days.
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