Montgomery County Unforeseen Emergency Withdrawal Form Page 2
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5PLEASE RETURN THIS FORM TO:
Regular Mail:
Overnight Mail:
Fidelity Investments
Fidelity Investments
VSEP: TEM HARDSHIP REQ
VSEP: TEM HARDSHIP REQ
PO Box 770002
100 Crosby Parkway, Mailzone KC1E
Cincinnati, OH 45277‐0090
Covington, KY 41015
Attn: Montgomery County
Attn: Montgomery County
TEM_HARDSHIP_REQ
By signing this application, I hereby acknowledge the following:
Upon approval of this request, I may not make deferrals for six (6) consecutive months to the Montgomery County Deferred Compensation
Plan.
I also represent and warrant that my unforeseen emergency cannot be relieved 1) through reimbursement or compensation by insurance or otherwise;
2) by liquidation of my assets, to the extent such liquidation would not itself cause severe financial hardship; or 3) by cessation of deferrals under the
Plan. I have attached the required documentation supporting this request for an unforeseen emergency (e.g., police report, explanation of health
benefits, etc.). All the facts I have presented above are true.
Your signature is required to process this form.
Participant's Signature:______________________________________________
Date:_______________________________________
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