Further information regarding IRS regulations relating to this subject can be found at the
Employee Information:
Service Provider Agent Information:
Tax Sheltered Annuity Account Information:
I am requesting to take a Unforeseeable Emergency distribution from my current employer's 457 account:
Unforeseeable Emergency Circumstances:
Please see our
457 Unforeseeable Emergency Information Sheet
for a list of acceptable documentation.
*Please identify which of the following circumstances have prompted this request for disbursement:
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Medical care expenses previously incurred by the employee, the employee's spouse, any dependents of the employee, or the employee's primary beneficiary under the 457 plan, necessary for these persons to obtain medical care (you must provide supporting documentation, e.g. doctor's certification, hospital bills).
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Costs directly related to the purchase of a principal residence for the employee (excluding mortgage payments) (you must provide supporting documentation);
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Payment of tuition, related educational fees, and room and board expenses, for the next 12 months of post-secondary education of the employee, or the employee's spouse, children, dependents, or primary beneficiary under the 403(b) plan (you must provide supporting documentation);
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Payment necessary to prevent eviction of the employee from the employee's principal residence or foreclosure on the mortgage on that residence (you must provide supporting documentation, e.g. bank's foreclosure notice);
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Payment of funeral expenses for the employee's spouse, dependent, or primary beneficiary under the 457 plan (you must provide supporting documentation, e.g. death certificate, funeral home bill);
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Certain expenses relating to the repair of damage to the employee's principal residence (you must provide supporting documentation, e.g. proof of loss, contractor's estimates, insurance adjuster's estimates).
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Expenses and losses (including loss of income) incurred by the Employee on account of a FEMA declared disaster, provided that the Employee's principal residence or principal place of employment at the time of the disaster was located in an area designated by FEMA for individual assistance with respect to the disaster.
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*Date Unforeseeable Emergency First Occurred:   
*Explanation of reason why Unforeseeable Emergency Distribution is needed:
If total amount being requested is not fully represented by supporting documentation, how did you arrive at the amount?:
Alternative Measures:
Please answer the following questions: