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Maryland Public Employees Deferred Compensation Program

FINANCIAL HARDSHIP REQUEST INSTRUCTIONS

THE ADMINISTRATION OF THE PLAN IS AUDITED FROM TIME TO TIME BY THE INTERNAL REVENUE SERVICE FOR

DETERMINATION OF FULL ADHERENCE BY ALL PARTIES TO THE REQUIREMENTS OF THE PLAN. IF THE PLAN

SHOULD NOT BE ADHERED TO, THE TAX BENEFITS OF THE PLAN CAN BE DENIED TO ALL PARTICIPANTS IN THE

PLAN. FOR THIS REASON, THE ADMINISTRATOR OR THE REVIEW COMMITTEE IN YOUR CITY/COUNTY, IF THERE IS

ONE, MUST ADHERE STRICTLY TO IRS REGULATIONS.

IRS regulations state that a hardship is an unforseeable emergency or “severe financial hardship” as a result of events beyond

the control of the Participant. Benefits to be paid shall be limited strictly to that amount necessary to meet the emergency

need constituting severe financial hardship. An unforseeable emergency constituting a “financial hardship” shall include

Sudden, Unexpected and Unreimbursed Major Expenses resulting from:

a) Illness of the Participant or his dependent

b) Accident of the Participant or his dependent

c) Disability of the Participant or his dependent

d) Major property loss due to casualty

e) Any other similar Extraordinary and Unforseeable circumstance arising as a result of events beyond the control

of the Participant.

Payment may not be made to the extent that such hardship may be relieved:

a) Through reimbursement or compensation by insurance or otherwise,

b) by liquidation of the Participant’s assets, to the extent the liquidation of such assets would not itself cause severe finan-

cial hardship, or

c) by cessation of deferrals under the Plan

NOT considered a “severe financial hardship” are forseeable personal expenses normally budgeted, such as:

1. Downpayment for a home or normal repairs to a home

2. Purchase or repair of an automobile

3. College or other educational expenses

4. Normal monthly bills

5. Payment of loans

IF YOU FEEL THAT YOU QUALIFY FOR A WITHDRAWAL OF FUNDS, PLEASE COMPLETE THE INFORMATION

REQUESTED ON THE ATTACHED SHEETS. INFORMATION MUST BE COMPLETE OR THIS FORM WILL BE RETURNED

FOR ADDITIONAL INFORMATION, THEREBY CREATING A DELAY IN CONSIDERATION. FOR YOUR REQUEST TO BE

CONSIDERED FOR APPROVAL, SUPPORTING DOCUMENTS MUST BE SUBMITTED WITH THIS APPLICATION. THE

FOLLOWING ARE EXAMPLES OF SUPPORTING DOCUMENTS THAT MIGHT BE SUBMITTED.

1. Medical bills (amount not covered by insurance)

2. Insurance statement showing amounts paid and amounts not paid

3. Applicable death certificate

4. Doctor’s statement verifying disability

5. Applicable separation or divorce agreement

6. Police or Fire accident report

7. Other documentation as may be needed

8. A W-4 must be submitted with this form.

THE PARTICIPANT SHOULD BE AWARE THAT ALL AMOUNTS RECEIVED ARE SUBJECT TO ORDINARY INCOME TAX,

MAY BE REQUIRED TO PAY AN ADDITIONAL 10% TAX TO THE IRS ON SUCH AMOUNTS RECEIVED. ALL TAX FORMS

WILL BE RECEIVED BY THE PARTICIPANT BY THE DEADLINE ESTABLISHED BY THE IRS FOR W-2 REPORTING.

You will be notified of whatever action has been taken regarding your claim. If you have any further questions concerning this

matter, please feel free to contact the Plan Administrator.

DC-1353-0313

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Form Dc-1353-0313 - Financial Hardship Request Instructions And Application Form Maryland

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