Montgomery County Unforeseen Emergency Withdrawal Form (Page 3 of 5) in pdf

Montgomery County Deferred Compensation Plan

APPLICATION FOR AN UNFORESEEN EMERGENCY WITHDRAWAL

In order to qualify for an unforeseen emergency withdrawal, your situation must meet one of the following Internal

Revenue Service (IRS) definitions of an unforeseen emergency.

1. A sudden and unexpected illness or accident not reimbursed by insurance;

2. Medical expenses not reimbursed by insurance

3. Residential Repair/Loss of property due to casualty and circumstances beyond your control

4. Prevention of foreclosure or eviction from a primary residence

5. Funeral expenses for a family member

6. Any other extraordinary and unforeseeable emergency.

Unforeseeable emergencies do not include the following:

1. Credit Card Debt (except when resulting directly and solely from illness or casualty loss)

2. Personal Bankruptcy (except when resulting directly and solely from illness or casualty loss)

3. Purchase of real estate

4. Payment of college tuition

Your Montgomery County Deferred Compensation Plan account is not a savings account, but a supplemental retirement

account. The tax laws regulating this Deferred Compensation Plan require that you have no other available source of

funds before requesting a Unforeseen Emergency withdrawal. If you have insurance, a regular savings account, or if

you have any assets, whereby the sale would help pay the expenses of your emergency, then you must first use these

resources before drawing on your Deferred Compensation Plan account. If the sale of an asset would cause you further

financial hardship, such sale is not required. Your request must be only for the amount necessary to cover your

unforeseen emergency and taxes and any penalties.

Funds distributed as an unforeseen emergency are not eligible for rollover to another qualified plan or IRA. The funds

are taxed at a rate of 10% unless you elect not to have withholding apply. If an election is NOT made, taxes will be

withheld at the rate of 10%.

You must include with your application the required documentation supporting your unforeseen emergency, including if

applicable, an explanation from your insurance company showing payments or denials.

Participants, who have received an Unforeseen Emergency withdrawal, are prohibited from making deferrals to the

Montgomery County Deferred Compensation Plan for six (6) months beginning the month following the withdrawal.

If Fidelity is unable to process your request, you may submit a written request for a review of your

Unforeseen Emergency request to Montgomery County. If your request is for a reason of Other similar

extraordinary and unforeseeable circumstances arising as a result of events beyond my control please

forward directly to:

Montgomery County Employee Retirement Plans

101 Monroe, 15

Floor

Rockville, MD 20850

If you have any questions please call Fidelity Investments at (800)343-0860 to speak with a Customer

Service Representative.

Montgomery County Unforeseen Emergency Withdrawal Form Page 3