State of New Mexico
Unforeseeable Emergency Distribution Application
Explanation &
Information
About
Requests for
Unforeseeable
Emergencies
As your Deferred Compensation Plan Administrator, we are pleased to provide you with information
regarding your request for an Unforeseeable Emergency.
An "Unforeseeable Emergency" is described in the State of New Mexico Plan Document under
Section 6 as:
"... required by the Treasury Regulations promulgated under Section 457 of the Code, as
a severe financial hardship to a participant resulting from a sudden and unexpected
illness or accident of the participant, or of a spouse, or of a dependent of the
participant, as defined in Section 152(a) of the Code, of the participant, loss of the
participant's property due to casualty, or other similar extraordinary and unforeseeable
circumstances arising as a result of events beyond the control of the participant.
Treasury Regulations provide that except in extraordinary circumstances, the need to
send a participant's child to college or the desire to purchase a home does not
constitute an Unforeseeable Emergency. In accordance with Deferred Compensation
Rules and Regulations, divorce does not constitute an Unforeseeable Emergency.
"(a) For purposes of this Section 6, an Unforeseeable Emergency is defined, as required
by the Treasury Regulations promulgated under Section 457 of the Code, as a severe
financial hardship to a Participant resulting from a sudden and unexpected illness or
accident of the Participant, of the Designated Beneficiary, or of a spouse, or of a
dependent of the participant or a Designated Beneficiary, as defined in Section 152(a)
of the Code, of the Participant, loss of the Participant’s or Designated Beneficiary’s
property due to casualty, or other similar extraordinary and unforeseeable
circumstances arising as a result of events beyond the control of the Participant.
Treasury Regulations provide that, “except in extraordinary circumstances,” the need to
send a Participant’s child to college or the desire to purchase a home does not
constitute an Unforeseeable Emergency. In accordance with Deferred Compensation
Rules and Regulations, divorce does not constitute an Unforeseeable Emergency.
(b) For purposes of this Section 6, an amount will not be considered to be reasonably
needed to meet the financial need created by an Unforeseeable Emergency to the
extent that such need is or may be relieved (i) through reimbursement or compensation
by insurance or otherwise, (ii) by liquidation of a Participant’s assets, to the extent the
liquidation of such assets would not itself cause severe financial hardship, or (iii) by
cessation of deferrals under the Plan."
If you feel that you may qualify for an Unforeseeable Emergency, please complete the attached
application and the W-4P Federal Tax Withholding Form and mail them to our office. Please note
that the amount you request for a withdrawal cannot exceed the current value of your account. If
your request is approved, all funds will be withdrawn on a pro-rated basis across all accounts,
according to your allocation percentages. Some mutual funds may impose a short term trade fee.
Please read the underlying prospectuses carefully.
If you currently have Life Insurance coverage through the plan, please be aware that if you choose
to stop your deferrals to obtain an Unforeseeable Emergency distribution to alleviate your
Unforeseeable Emergency, your policy may lapse and your coverage will no longer be in effect.
Please contact our office to discuss the options available to you to continue your life insurance
coverage.
Please return the completed application and the attached W-4P to:
NATIONWIDE RETIREMENT SOLUTIONS
P. O. BOX 182797
COLUMBUS, OH 43218-2797
If you require assistance with the completion of the attached forms or have any questions, please
call us at 1-866-827-NMEX(6639).
Nationwide Retirement Solutions • P.O. Box 182797 • Columbus, OH 43218-2797 • 1-866-827-NMEX(6639) • www.newmexico457dc.com
DC-4072-0714
State of New Mexico
Unforeseeable Emergency Distribution Application
Participant
Information
Participant Name:
Social Security Number:
Current Address:
City:
Unforeseeable
Emergency
State:
Zip Code:
Contact Phone Number:
Email Address:
Employer Name:
Employer Number:
To qualify for an unforeseeable emergency distribution, the participant must experience a severe financial hardship
that is a result of an extraordinary and unforeseeable event beyond the designated beneficiary, spouse, or
dependent’s control that cannot be relieved using funds available from their checking, savings, stocks, mutual funds,
securities, insurance, other assets or by ceasing their deferrals.
Non-approvable events generally include:
u routine monthly expenses
u annual tax liability
u purchase of a car
u education expenses
u maternity leave
u loss of overtime/holiday pay u purchase of a home u elective/cosmetic surgery
u home or auto maintenance u routine medical expenses
u elective orthodontia u divorce legal fees
Please describe the participant’s (designated beneficiary’s, spouse or dependent’s) severe financial hardship.
1. Was the severe financial hardship a result of an illness of the participant (designated beneficiary’s, spouse or
dependent’s)?
Yes r No r If yes, describe
2. Was the severe financial hardship a result of an accident of the participant (designated beneficiary’s, spouse or
dependent’s)?
Yes r No r If yes, describe
3. Was the severe financial hardship a result of a loss of the participant’s (designated beneficiary’s, spouse or
dependent’s) property due to casualty?
Yes r No r If Yes, describe
4. Was the severe financial hardship a result of some other similar extraordinary and unforeseeable circumstances
arising as a result of events beyond the control of the participant (spouse or dependent’s)? Yes r No r If yes,
describe.
State of New Mexico
Unforeseeable Emergency Distribution Application
Unforeseeable
Emergency
(continued)
Please select the reason for your unforeseeable emergency request from the following list. Please realize you will
be required to submit documentation to support your request.
r
Property Loss Due To Accident /Casualty
- requests that are the result of an accident or casualty
- medically necessary items are approvable (e.g. heat, air conditioning, water heater)
r
r
Official Police Report (where applicable).
If the participant has insurance: a letter from the participant’s insurance company indicating
the amount covered by insurance and deductible amount owed, or reasons for no coverage.
r
r
r
q
Imminent Foreclosure/Eviction
- threat of foreclosure/eviction on the participant’s primary residence
q
q
q
q
q
Letter must be dated within the past 60 days.
Letter from the auto loan company indicating a dollar amount needed to prevent repossession
of your primary automobile.
Medical/Dental/Prescription Expenses, includes the following scenarios:
- incurred or future expenses for the participant, their spouse or dependent
- not covered by insurance
- medical necessity
- rehabilitation expenses
- covered services do not include check-ups
r
r
r
r
Letter from the mortgage company indicating a dollar amount needed to
prevent imminent foreclosure or acceleration on the participant’s primary residence.
m
Documentation showing the property address of the loan under the
threat of foreclosure.
Letter from the landlord/leasing agency or court ordered eviction notice
indicating the dollar amount needed to prevent imminent eviction from primary residence.
Default letters can be submitted as proof of imminent foreclosure or eviction.
Car Repossession
- requests for the participant’s primary vehicle
q
r
If the participant does not have insurance: a signed statement from the participant indicating
that they do not have insurance.
Detailed repair estimate from a licensed mechanic indicating the make and model of the
vehicle in need of repairs (for auto repairs).
Detailed repair estimate from a licensed contractor indicating the specific causes of the
damage to the participant’s primary residence (for home repairs).
If the participant has insurance: Explanation of Benefits forms from the insurance company
indicating insurance coverage (or reasons for no coverage), patient responsibility, and dates of
service for all charges.
If the participant does not have insurance: Detailed bills indicating dates of service for all
charges and a signed statement indicating that the participant does not have insurance.
If the procedure could be considered cosmetic, a letter from a medical doctor/dentist
indicating the reasons why the procedure is medically necessary.
m Documents must be dated within the past 24 months.
m For future services: Pre-treatment estimate indicating insurance coverage & patient
responsibility for all procedures that are to be performed; anticipated date of service;
statement from provider showing that payment must be made before treatment will be
rendered.
Utility Disconnection
- expense requests for gas, electric, water, or heating
r
Letter from the utility company indicating the dollar amount needed to prevent imminent
disconnection of the gas, electric, water or heating services at the participant's primary
residence.
State of New Mexico
Unforeseeable Emergency Distribution Application
Unforeseeable
Emergency
(continued)
r
Funeral
- funeral expenses that are the responsibility of the participant (descendent does not have to be
immediate family)
r
r
Detailed invoice from a funeral home that itemizes the cost of the funeral expenses for which
you are responsible.
q
Copies of receipts, booking information (air, hotel)and other travel expenses.
Moving Expenses
- circumstances for the move must be unforeseeable & beyond the participant’s control. For example: an
approvable divorce/separation situation; loss of an established roommate of which the participant &
roommate were both named on the lease, ownership of the property has changed & the participant’s
family must move per the new owners; foreclosure.
- cannot approve for the first month’s rent; moving expenses due to a lease ending and it not
being renewed; cannot approve new furniture expenses.
r
r
q
q
r
Rental/lease agreement.
Copies of bills/receipts for moving expenses.
The following are examples of expenses:
m Security deposit; utility hook up charges; appliance purchase may be approved (within
reason; must be necessary - e.g. the stove and refrigerator may be approved, but not a
microwave); moving van/truck rental may be approved.
For expenses yet to be incurred, copy of lease agreement or letter from landlord/leasing
agency outlining the deposit amounts due before the lease can be signed; estimate from
moving truck company or moving company.
If related to divorce, a copy of the legal separation agreement, initial complaint for divorce or
final divorce decree.
Involuntary Loss of Income
- must be incurred losses from the participant or spouse
- the loss may be approvable for up to 36 months back with documentation
- the loss may be approvable for six months in the future with proper documentation and a return to
work date
- the reason for the loss must be for medical reasons of the participant/spouse or due to a separation
without cause/layoff/downsizing, commission based positions (real estate sales, etc.) due to slow sales, lost
overtime, holiday pay, and suspensions without pay
- loss can be full-time or part-time employment as long as that income can be documented as consistent
- income is considered consistent after 6 months in the same position or 12 months of steady employment
- cannot approve for loss of income from rental property or termination with cause
r
r
r
r
r
r
r
r
Letter from employer indicating dates of employment and UNPAID dates of work missed due to
involuntary reasons. This must indicate any sick pay, vacation pay, worker’s compensation,
unemployment benefits or any other form of compensation received while out of work.
A Loss of Income Verification form completed by the participant’s employer can replace the
letter described above.
Copy of the participant’s (or spouse’s) most recent pay stub indicating their regular pay rate.
m Can accept W-2 forms if a pay stub is not acquirable (in cases of divorce/separation)
Documentation from the Worker’s Compensation Board, Disability board, or Department of
Labor regarding the participant’s (or spouse’s) unemployment benefits, disability benefits, or
unemployment eligibility, the date the benefits began/will begin, the amount of the benefits,
and the date benefits will/may end.
If from a second job, a letter from employer showing dates of employment and termination.
If related to divorce, a copy of separation agreement, initial complaint for divorce, or final
divorce decree.
If from personal business, a letter from licensed physician indicating dates of loss of income.
A new application will be required for each subsequent withdrawal.
Items to keep in mind to prevent your request from being delayed or denied:
u If your unforeseeable emergency distribution is due to a legal dependent's situation, we will require a copy of
the qualified dependent worksheet to show dependency
u Documentation being supplied from third parties must be on third party’s letterhead
u The documentation provided must generally be dated within the previous 12 months
u Sign your application and the tax forms provided (if applicable)
u Please allow up to 10 days for receipt and review
All Documentation will be reviewed and does not guarantee approval of your request.
Please note that additional documentation may be requested.
State of New Mexico
Unforeseeable Emergency Distribution Application
What dollar amount are you requesting?(Applications without a stated request amount cannot be approved.)
........................................................
Amount
Requested
Delivery
Options
If approved, how would you like your funds to be delivered? (Please check all that are applicable)
r Check – From date of issuance please allow 5-7 business days for receipt
r Overnight – A $25.00 fee will be deducted from your account pro rata
r ACH – Please complete direct deposit information below
Please Note: If none of the above options are selected funds will be issued as a check and
distributed via standard mail.
Direct
Deposit
Information
Check only one option:
r Checking Account
r
_____________________________________________________
Bank/Credit Union Name
ABA NUMBER (First nine digits only)
Savings Account
_____________________________
Account Number
I: /____/____/____/____/____/____/____/____/____/ I:
Your ABA number appears at the bottom of your checks between the markings indicated above.
Bank or Credit Union Telephone Number: (
)____________________________________
Note: Direct Deposit is only offered through members of the Automatic Clearing House (ACH).
Is this account associated with a brokerage firm or other investment firm?
r Yes r No
If yes, have you confirmed that the ABA and account numbers are correct? r Yes r No
Please note: You must include a voided check if your distribution is being sent to your
checking account.
Tax
Information
All distributions are subject to federal, applicable state and local taxes. Federal Income Tax will be withheld from your
payment as required by the Internal Revenue Code. Payments will be reported on a 1099-R form.
Please select the method to handle your tax withholding:
Use the default rate of 10% for Federal Taxes (unless otherwise directed with this form or an attached W-4P, all
unforeseeable emergency withdrawals will use a default rate of 10% for Federal Taxes) If choosing to use the
default rate, check here r if you wish to increase your distribution to pay for the 10% tax withholding.
r
r
Please use the withholding I designated on the attached W-4P form
r
Do not withhold Federal taxes from my withdrawal. I will be liable for all Federal taxes that may result from this
withdrawal
Certification
Under penalty 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.
Signature &
Authorization
I verify that all information provided on this application is current, complete, and accurate. I verify that my event
may not be relieved using funds available from my checking, savings, stocks, mutual funds, securities,
insurance, other assets or by ceasing my deferrals.
I understand it is my responsibility to and I agree to maintain the documentation supporting this unforeseeable
emergency request.
I understand that these funds may not be rolled over into an IRA, 401, 403(b), or another 457 plan.
I understand that if I am still deferring to the Plan, my request for unforeseeable emergency withdrawal may be
denied.
Thank you for your participation in the deferred compensation program. If you have any questions, please call
us at 1-866-827-NMEX.
The Internal Revenue Service does not require your consent to any provision of this document other than the
certifications required to avoid backup withholding.
Participant’s Signature
Date
Nationwide Retirement Solutions • P.O. Box 182797 • Columbus, OH 43218-2797 • 1-866-827-NMEX(6639) • www.newmexico457dc.com
DC-4072-0714
Loss of Income Verification
Please
Read
Employee
Information
This form is to be completed by your employer and returned to Nationwide Retirement Solutions as
soon as possible to aid in your request.
Name of Employee:
Employee’s Social Security Number
Date Employed:
Employee’s Hourly Rate:
Dates of Work Missed:
FROM_______________________________________
TO ______________________________________
Unpaid Dates of Work Missed Due to Involuntary Reasons:
(If the dates missed are not consecutive, please list them below in the Additional Comments section)
FROM_______________________________________
TO ______________________________________
Is the employee eligible for or have they received worker’s compensation?
r Yes
r No
If yes, how much are they eligible for or how much have they received?
Is the employee eligible for or have they received disability benefits?
r Yes
r No
If yes, how much are they eligible for or how much have they received?
Has the employee used up all available sick time, vacation time, or any other type of accruals available to them?
r Yes
r No
If no, how much sick time, vacation time, or other accruals do they have available for use?
Reasons why the dates missed were unforeseeable and beyond the employee’s control:
Additional Comments:
Employer
Information
and
Authorization
This section is to be filled out and signed by the person who completed this form. Please complete
this form in its entirety. Questions left unanswered may result in further delay.
Name:
Title:
Phone Number:
Signature:
Date:
W-4P Federal Tax Form Instruction Sheet
PURPOSE OF FORM:
The purpose of the W-4P Form is to provide your deferred compensation plan administrator with the federal tax
information necessary to process your payout. PLEASE NOTE: We do not require that you complete the Personal
Allowances Worksheet or the Multiple Pensions/More Than One Income Worksheet. However, we do require that
you complete the “Withholding Certificate for Pension or Annuity Payments Section” as indicated below.
INFORMATION REQUIRED: (Please print or type all information)
Name & Address Information:
w Name - First, Middle, Last
w Your Social Security Number
w Your Home Address - include apartment number or rural route if applicable
w City, State and Zip Code
w Claim or Identification Number of Pension/Annuity Contract (not applicable)
Tax Information:
1. Place an “X” in the box if you elect not to have income taxes withheld
2. Indicate the Number of Allowances and place an “X” in the box indicating your marital status.
3. Indicate any additional federal tax amount you want withheld from each annuity check.
Sign and date the W-4P Form and attach it to your Unforeseeable Emergency application. Return both forms to
Nationwide Retirement Solutions, P.O. Box 182797, Columbus, OH 43218-2797.
W-4P Federal Tax Form Instruction Sheet
We do not require you submit a W-4P form in order to process your payout
request. However, you may wish to complete and submit the attached form if
you wish to have more federal income tax withheld than is required.
Refer to the “Special Tax Notice Regarding Plan Payments” for information about
what payments are eligible for rollover.
If your payment is an eligible rollover distribution, federal regulations
require that 20% of the payment be withheld.
If your payment is not eligible for rollover, the default federal
withholding is 10% for lump sum payments and married with three
exemptions for periodic payments.


If submitting the form, provide the following information (print or type all
information):
Name & Address Information:
 Name – First, Middle, Last

Your Social Security Number

Home Address – Include apartment number or rural route if applicable

City, State, Zip Code

Claim or Identification Number of Pension/Annuity Contract
Tax Information:
1. Place an “X” in the box if you elect not to have income taxes withheld
2. Indicate Number of Allowances, in addition, place an “X” in the box that
indicates your marital status
3. Indicate any additional federal tax amount you want withheld from each
annuity check.

Sign and Date the form
NRI-0359AO.5
DC-2353-0114