Montgomery County Unforeseen Emergency Withdrawal Form (Page 4 of 5) in pdf

Montgomery County 457(b) Plan

Unforeseen Emergency Withdrawal Rules

Unforeseeable Emergency

Documentation Requirements



Eviction/ Foreclosure of a primary

Must submit an Eviction/Foreclosure Notice, dated within the

residence

past 30 days. The Notice must be on the mortgage company

or leaser’s letterhead. Participant’s name must be on the

Notice.

If the participant’s name is not on the Notice the

address on the Notice must be the participant’s address on file

with Fidelity.



The Notice must list the total amount needed to prevent

foreclosure or eviction. The withdrawal request may include

legal or court costs when shown on the Notice.



The notice must indicate a future date due—this includes 3, 5

or 7 day notices for eviction.



If the home is being sold to pay taxes, participant must provide

a Tax Sale Notice.



Notice

letter

requesting

current

past

due

rent/mortgage/tax payment is not acceptable.



A request to pay the difference between the sales price of the

home and the mortgage is not acceptable.



Sudden and Unexpected Illness or Accident

An Explanation of Benefits (EOB) from an insurance

not reimbursed by insurance/Medical

company/medical plan or medical bill dated within the past 12

Expenses

months, with dates of service provided within the last 2 years,

showing the amount paid by insurance/medical plan.



If the patient’s last name is different from the participant’s,

then proof of dependency is required. A tax return showing

dependency is required.



Court order and collection notices without the EOB or medical

bills do not qualify.



Medical bills stating self-pay, has no insurance, or if item is

clearly listed as a co-pay may be approved.



Travel expenses such as to visit a specialist may be approved.



Dental estimates and treatment plans are acceptable as long

as they indicate what the insurance will or will not cover.



Medical expenses must be listed a deductable medical

expenses in IRS Publication 502 and documentation of medical

necessity may be required.



Funeral/ Burial

Bill dated within the past 6 months in the name of the

participant.



Expenses must relate to an immediate family member (i.e.,

spouse or dependent as defined in IRC Section 152(a)).



Funeral expenses already paid cannot be reimbursed.

November 2013

Montgomery County Unforeseen Emergency Withdrawal Form Page 4

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