City of Tempe Savings and Investment Plan 401(k) Financial ...

SECTION I: Participant Information

Participant Name: Current Address: Contact Phone Number:

Date of Birth

City of Tempe Savings and Investment Plan 401(k) Financial Hardship Application

Social Security Number:

City, State, Zip Code:

Email Address

SECTION II: Reason for Hardship Withdrawal

SECTION III: Available Options

Information requested on this form is used by the Deferred Compensation Committee for purposes of identification and account processing. You must furnish all the information requested on this form. Failure to provide the information may result in the action requested not being processed.

A financial hardship will be deemed to exist if the Participant experiences an immediate and heavy financial need and has no other resources available to meet such need. The Deferred Compensation Committee shall determine whether the above criteria are met by reference to the following guidelines:

r Medical expenses as well as expenses necessary to obtain medical care for the Participant, the Participant's Spouse or the Participant's dependants. Please attach a copy of the medical bills or estimates.

r Costs directly related to the purchase (excluding mortgage payments) of a principal residence for the Participant. Please attach a copy of the purchase agreement.

r Payment of the next twelve months' tuition and related expenses for a post secondary education for the Participant, the Participant's Spouse, or the Participant's dependants. Please attach a copy of the tuition statement.

r Payments necessary to prevent the eviction of the participant from his or her principal residence or to prevent foreclosure on the mortgage on that residence including rent or mortgage payment. Please attach the eviction or the intent to foreclose notice.

Note: 1.) If approved and assets are withdrawn, your elective deferrals into your 401(k) and 457(b) Plan will be stopped for six (6) months following the date of the withdrawal. This also means any employer match will be stopped for 6 months. 2.) No more than one (1) withdrawal may be made in any plan year without the consent of the Deferred Compensation Committee. 3.) All withdrawals will be limited solely to elective deferrals only.

Can this hardship be completely or partially relieved through the following options: Yes No

r r Reimbursement or payment by insurance or other sources? r r The reasonable liquidation of assets, provided the liquidation would not itself cause an

immediate heavy financial need? r r The cancellation of elective deferrals under the 401(k) Plan and/or 457 Deferred

Compensation Plan?

r r Other currently available distributions or nontaxable loans from other plans maintained by City of Tempe or any other employer?

r r Borrowing from commercial sources on reasonable commercial terms in an amount sufficient to satisfy the need?

If you answered "Yes" to any of the five questions above, you are ineligible for a hardship withdrawal until the option(s) for which you have answered "Yes" have been exhausted or until you can provide documentation that your hardship cannot be

SECTION IV: Request for Withdrawal

r Do not withhold federal taxes from my withdrawal. I will be liable for all federal taxes that may result from this withdrawal, including penalties if applicable.

r Check here to increase approved distribution amount by 20% to include the amount of any taxes and penalties which may occur as a result of the Hardship withdrawal distribution. Important note, you may be subject to additional taxes, please consult a tax advisor for additional information.

If you answered "NO" to all of the questions in Section III and your request is approved, the City of Tempe will be notified and your elective deferrals (457 and 401k) will be stopped for 6 months. The employer match may be stopped for six (6) months if approved.

Amount Requested for Withdrawal: $_______________________________________

DC-4836-0614

Nationwide Retirement Solutions ? 4747 N. 7th St., Suite 418 ? Phoenix, AZ 85014 ? 1-877-652-5115 ?

SECTION V: Certification SECTION VI: Participant Authorization Information

Instructions

Contact Information

DC-4836-0614

Financial Hardship Statement for 401(k) Plans

Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number (Or I am waiting for a number to be issued to me), and 2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and 3. I am a U.S. citizen or other U.S. person.

I request a hardship withdrawal to be made in accordance with the Plan Document, Internal Revenue Code (IRC), and my election. I understand that federal income tax of 10% will be deducted from the amount approved unless I otherwise specify. I hereby certify under penalty of perjury that this information is true and accurate to the best of my knowledge.

The Internal Revenue Service does not require your consent to any provision of this document other than the certification required to avoid backup withholding.

______________________________________________________________ _______________________________

Signature

Date

Your decision regarding a hardship withdrawal may have finan- Definition of Dependant

cial consequences as well as income tax implications. Therefore, you may wish to obtain the advice of a tax advisor before you request a hardship withdrawal.

The definition of "dependant" is set forth in IRC Section 152 as either a "qualifying child" or a "qualifying relative."

Do not complete this form if you have separated or retired from City service, or reached the age of eligibility and desire a distribution. Contact Nationwide to request Payout Paperwork.

A qualifying child is someone who meets all the following

criteria: ?Is a child or brother or sister (or stepbrother a or stepsister) of the participant or a descendant of either.

?Has the same principal place of residence as the partici-

The amount available for a hardship withdrawal is based on your contributions only. The Internal Revenue Code (IRC) Section

pant for more than one-half the taxable year ?Has not yet turned age 19 (or is a student who has not yet

401(k) does not allow hardship withdrawals from accrued interest or earnings, and your Plan does not permit hardship withdrawals

turned age 24) as of the ?Has not provided more

end of the taxable year. than one-half of his or her

own

from the 401k employer match contributions.

support for the taxable year.

To meet the criteria for a 401(k) hardship withdrawal, you must first exhaust all other options. Refer to Section III.

A qualifying relative is someone who meets all the following criteria:

You will be responsible for federal and state income tax and

?Is a child (or descendant), brother or sister (or stepbrother or stepsister), father or mother (or ancestor), stepmother or

applicable penalties on the amount withdrawn. Federal taxes will be withheld at a rate of 10% unless you request otherwise by

stepfather, niece or nephew, aunt or uncle, or in-law (father, mother, sister, brother, son, or daughter) or the par-

checking the box in the Request for Withdrawal Section. State taxes will not be withheld unless you request otherwise by

ticipant or has the same principal place of residence as the participant (other than spouse) and is a member of the

completing a Annuitant's Request for Voluntary Arizona Income Tax Withholding. If you are younger than age 59 1/2, you may

participant's household. ?Has a gross income in a taxable year of $3,650 (for 2009)

be liable for an additional 10% federal tax penalty, if applicable. A 1099-R will be issued by January 31 of the following year for

or less. ?Receives more than one-half his or her support in that

reporting purposes.

taxable year from the participant.

?Is not a "qualifying child" of any taxpayer in the taxable

Once all necessary documentation has been received, your request will be reviewed and a decision will be rendered within

year.

3-5 business days.

For purposes of a hardship application for education

expenses or funeral expenses, a "dependant" is any person

who meets the definition of qualifying relative irrespective

of his or her gross income or irrespective of whether he or

she is also a qualifying child of any taxpayer.

SECTION I- Participant Information

Complete the information requested.

SECTION II- Reason for Hardship Withdrawal

Check all boxes that apply. Please submit copies of documents. The purchase agreement must be signed by the buyer and the seller and include a closing date.

SECTION III- Available Options

Check "Yes" or "No" in response to questions.

SECTION IV- Request for Withdrawal

Check the box(es) that are applicable to your request.

SECTION V- Participant Certification

Read carefully, sign and date the form.

Mail the original form (do not fax) to:

Nationwide Retirement Solutions 4747 N. 7th St., Suite 418 Phoenix, AZ 85014

Voice Response System: 1-877-652-5115, 24 hours a day, 7 days a week

Customer Service: 1-877-652-5115, 8:00 a.m. - 11:00 p.m. (ET), Monday-Friday To speak with a customer service representative, press "0"

Website:

Nationwide Retirement Solutions ? 4747 N. 7th St., Suite 418 ? Phoenix, AZ 85014 ? 1-877-652-5115 ?

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