UNFORESEEABLE EMERGENCY WITHDRAWAL REQUEST
FROM AN ELIGIBLE 457(B) PLAN
To check the status
of your request or ask
any questions:
Call 800-842-2252
Weekdays
8 a.m. – 10 p.m. (ET)
Saturday
9 a.m. – 6 p.m. (ET)
Your decisions regarding an unforeseeable emergency withdrawal will have financial consequences­as well as
income tax implications. Therefore, you may wish to obtain the advice of a tax advisor before you request an
unforeseeable emergency withdrawal.
To meet the criteria for an unforeseeable emergency withdrawal, you must first exhaust all other financial
options available to meet the need.
Consideration for unforeseeable emergency withdrawals will not be made in cases where the participant had
significant control and failed to exercise prudent judgment. Some examples of this would be abuse of credit
cards, obligations related to investments, business ventures, gambling debts or any violations of law.
Please be aware that completion of this request is necessary and that consequences of not taking this
process seriously could affect your ability to take a withdrawal from the plan. The IRS pays close attention
to unforeseeable emergency withdrawals­. You are therefore­urged to consider this request carefully.
Print in upper case using black or dark blue ink and provide all information requested.
The IRS defines unforeseeable emergency as a severe financial hardship to the participant­or beneficiary
resulting from:
(i)A sudden and unexpected illness or accident of the participant, a beneficiary, or the participant’s­
or beneficiary’s spouse or dependent (see Section 2 for definition of dependent);
(ii) Loss of the participant’s or beneficiary’s property due to casualty; or
(iii)Other similar extraordinary and unforeseeable circumstances arising as a result of events beyond
the control of the participant or beneficiary.
Furthermore, withdrawals are permitted to the extent the hardship cannot be relieved:
(i) Through reimbursement or compensation from insurance or otherwise;
(ii)By liquidating or accessing personal assets, including those associated with freely distributable­amounts
held in retirement and tax-sheltered savings plans (to the extent this would not itself cause severe
financial hardship); or
(iii) By stopping deferrals under the plan.
The amount available for distribution is limited to the amount necessary to satisfy the emergency need,
including any amounts necessary to pay federal, state or local income taxes or penalties reasonably
anticipated to result from the distribution.
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F11343 (10/16)
UNFORESEEABLE EMERGENCY WITHDRAWAL REQUEST
FROM AN ELIGIBLE 457(B) PLAN
A thorough review of a
request for an unforeseeable
emergency withdrawal will
be conducted based on the
facts and circumstances
specific to each case.
IMPORTANT: Supporting
documentation will be
required for each type of
unforeseeable emergency
request. Documents will not
be returned. Please send
us copies and keep your
originals.
The following is a list of specific events that generally would or would not be considered qualifying­
unforeseeable emergency events unless the situation itself resulted from an unforeseeable emergency
described earlier. This list is not comprehensive and is being provided as a guide. The events listed below do
not guarantee approval or denial of a claim. All claims are reviewed on an individual basis and are based on
the facts and circumstances of each case.
SITUATIONS TYPICALLY NOT ELIGIBLE FOR UNFORESEEABLE EMERGENCY WITHDRAWAL
Purchase of a home or real estate
„„ Payment of college tuition or other educational expenses
„„ Normal monthly bills such as utility bills, rent or mortgage payments (except in the event of imminent
foreclosure or eviction)
„„ Loan repayments
„„ Personal bankruptcy (except when resulting directly and solely from illness, casualty loss or other similar
extraordinary and unforeseeable circumstances beyond your control)
„„ Payment of income taxes, property taxes, back taxes, interest, fines or penalties (unless they are associated
with an approved unforeseeable emergency withdrawal)
„„ Credit card debt
„„ Purchase of an automobile
„„ Any elective surgery not covered by medical insurance
„„ Routine medical and dental bills, elective/cosmetic surgery, or orthodontia
„„
SITUATIONS THAT MAY BE ELIGIBLE FOR AN UNFORESEEABLE
EMERGENCY WITHDRAWAL
Sudden and unexpected medical condition not previously diagnosed or treated (regarding you, your
spouse, or your dependent)
„„ Costs associated with rebuilding the participant’s or beneficiary’s home following damage­not covered
by insurance due to casualty loss from natural disasters (e.g., fire, flood, hurricane, tornado, etc.), where
subject of loss is necessary for home habitability
„„ Emergency major repair or replacement of your or your spouse’s automobile needed for transportation to
and from work due to accident, theft, fire, flood, or other natural disaster
„„ Imminent foreclosure or eviction from the participant’s or beneficiary’s primary residence (the presence
of these events alone do not guarantee an approval)
„„ Replacement of wages for you or your spouse where loss of wages is due to involuntary absence from
work without pay due to sudden and unexpected illness or accident or extraordinary and unforeseeable
circumstances arising as a result of events beyond your control (e.g., termination without cause) and where
the absence is for at least 4 weeks
„„ Funeral expenses of the participant’s or beneficiary’s deceased parent, spouse, child or dependent, or
travel expense to attend funeral of a spouse or dependent
„„
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F11343 (10/16)
UNFORESEEABLE EMERGENCY WITHDRAWAL REQUEST
FROM AN ELIGIBLE 457(B) PLAN
Page 1 of 15
Please print using black or
dark blue ink.
IMPORTANT: A full Social
Security Number/Taxpayer
Identification Number is
required to process your
request.
If you claim residence AND
citizenship outside the U.S.,
you must complete Form
W-8BEN in addition to this
form to certify your foreign
tax status. To print the
W-8BEN form, go to
TIAA.org/forms, and scroll to
Find tax forms.
The Plan and Sub Plan
Numbers should have been
provided when you requested
the form. If you don’t have
them, please reference your
quarterly statement.
1. PROVIDE YOUR INFORMATION
First Name
Last Name
Suffix
Social Security Number/
Taxpayer Identification Number
Contact Telephone Number
Extension
State of Legal Residence
(if outside the U.S., write in Country of Residence)
Citizenship (if not U.S.)
2. PROVIDE YOUR CONTRACT NUMBERS
TIAA Number
CREF Number
Plan Number
Plan Name
TAEFT/OTCEMWTPUB
F11343 (10/16)
Middle Initial
Sub Plan Number
UNFORESEEABLE EMERGENCY WITHDRAWAL REQUEST
FROM AN ELIGIBLE 457(B) PLAN
Page 2 of 15
* If this request is being
made due to an
unforeseeable emergency
incurred by a spouse,
beneficiary, or dependent,
be sure to provide proof of
dependent or beneficiary
status. Examples include:
federal tax return showing
dependent status,
beneficiary designation,
copy of qualifying relative
federal income tax return,
proof of relationship, proof
of adult student status,
proof of disability for
qualifying child, proof of
adoption or foster child
status.
TAEFT/OTCEMWTPUB
F11343 (10/16)
3. DEPENDENT/BENEFICIARY INFORMATION
This request is related to (select all that apply):
Self Beneficiary* Spouse* Dependent Domestic Partner* Dependent*
The dependent definition in IRC Section 152 will be applied to unforeseeable emergency determinations.
Section 152 defines “dependent” as either a “qualifying child” or a “qualifying relative”.
IRC Section 152 qualifying child:
1. Must be the participant’s son, daughter, stepson, or stepdaughter; or an individual legally adopted by the
participant or placed with the participant for legal adoption; or the participant’s eligible foster child;
or the participant’s grandchild, brother/sister, stepbrother/stepsister, or niece/nephew.
2. Must have the same principal residence as the participant for more than one-half of the year.
3. Must not provide more than one-half of his or her own support for the year.
4. Must be under age 19 (or age 24 if a full-time student) at the end of the calendar year (unless
permanently and totally disabled).
IRC Section 152 qualifying relative:
1. Cannot be the qualifying child of any participant.
2. Must be the participant’s child, grandchild, brother/sister, stepbrother/stepsister, father, mother,
stepfather, stepmother, grandfather, grandmother, niece/nephew, aunt, uncle, son-in-law, daughter-in-law,
father-in-law, mother-in-law, brother-in-law, or sister-in-law. Alternatively, other than a spouse, the individual
could be any person who has the same principal place of abode as the participant and is a member of
his or her household.
3. Must receive over one-half of his or her support from the participant.
UNFORESEEABLE EMERGENCY WITHDRAWAL REQUEST
FROM AN ELIGIBLE 457(B) PLAN
Page 3 of 15
4. ALTERNATE FUNDING VALIDATION
Please choose “Yes” or
“No” for each question
confirming if all other
methods of funding have
been exhausted prior to
submitting a request for a
unforeseeable emergency
withdrawal.
If Yes, please identify source of reimbursement:
If you need more space,
please continue on a
separate page. Be sure to
write your name and
TIAA plan number on all
attachments.
Have you sold or otherwise liquidated any assets?
Attach copies of distribution
statement or loan denials
from the source.
Your plan may require
suspension of future
contributions as a
condition of receiving an
unforeseeable emergency
withdrawal.
Can this hardship be completely or partially relieved through the following options:
Will you be reimbursed or compensated by insurance?
No No Yes
Yes
If Yes, please describe; If No, state reasons why:
Have you voluntarily ceased deferrals to all retirement and deferred compensation plans before requesting
this withdrawal? (examples include: 401(k), 403(b), 457(b), etc.)
No Yes
If Yes, when stopped; If No, please explain why not and be advised that stopping deferrals to a retirement or
deferred compensation plan is considered to be an additional source of income available to you that would
at least partially alleviate your financial hardship. The cessation of deferrals is one of many factors that will
be considered during this determination.
TAEFT/OTCEMWTPUB
F11343 (10/16)
UNFORESEEABLE EMERGENCY WITHDRAWAL REQUEST
FROM AN ELIGIBLE 457(B) PLAN
Page 4 of 15
If you need more space,
please continue on a
separate page. Be sure to
include your name and plan
number on the attachment.
5. DESCRIPTION OF EMERGENCY
Have you applied for loans from credit unions, banks or other commercial sources to cover the financial need?
AmountSource
Yes $
Approved OR Denied
If denied, state reason given:
No
If No, state reason:
Please describe the financial hardship and why you consider it to be an unforeseeable emergency.
Why was this emergency unexpected?
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F11343 (10/16)
UNFORESEEABLE EMERGENCY WITHDRAWAL REQUEST
FROM AN ELIGIBLE 457(B) PLAN
Page 5 of 15
Documentation must be
provided that corresponds
to the Amount Needed for
Emergency.
6. DISTRIBUTION REQUEST
The amount available for distribution is limited to the amount necessary to satisfy the emergency need and,
if elected below, any amounts necessary to pay federal, state or local income taxes or penalties reasonably
anticipated to result from the distribution. If you elect to increase the withdrawal amount to include income
tax withholding, the withdrawal amount in the right-hand box will equal the amount of your unforeseeable
emergency plus the gross-up for tax withholding. If you do not elect to increase the withdrawal amount to
include income tax withholding, the withdrawal amount in both of the boxes below will be the same and will
equal the amount of your unforeseeable emergency withdrawal request.
Amount of Withdrawal Requested
Amount Needed for Unforeseeable Emergency
$
(please see below before completing)
$
If requested amount is not available, TIAA will process the maximum amount available without closing the
account. Your unforeseeable emergency withdrawal will be made on a pro-rata basis based on all of your
available funds.
The amount available for distribution is limited to the amount necessary to satisfy the emergency need
including any amounts necessary to pay federal, state or local income taxes or penalties reasonably
anticipated to result from the distribution.
Do you want the withdrawal increased to cover the federal and state income tax withholding? Please note
that TIAA can only increase payments for income tax withholding if you elect to withhold taxes (you may
indicate your tax withholding preferences in Section 7).
Yes No (If no selection is made, the withdrawal will not be increased to cover taxes.)
The following information is being provided to assist you in calculating the Amount of Withdrawal Requested if you elected
“Yes, increase the withdrawal amount to cover federal and state income tax withholding”
Calculation used to determine increase:
100% - Tax% (federal/state/local taxes) = Net%
Payment/Net% = Total amount withdrawn from your account
Example:
Withdrawal amount requested to cover the actual emergency: $1,000.00
Withhold FEDERAL income tax at the rate of 10%; withhold STATE income tax at the rate of 3% (total is 13%)
1. 100% - 13% = 87%
2. 1,000/.87= $1,149.43
Total amount withdrawn from your account: $1,149.43
Explain why you are requesting this particular amount and how it will solve your financial problem:
TAEFT/OTCEMWTPUB
F11343 (10/16)
UNFORESEEABLE EMERGENCY WITHDRAWAL REQUEST
FROM AN ELIGIBLE 457(B) PLAN
Page 6 of 15
You may be subject to a
10% federal tax penalty
for early withdrawal if the
unforeseeable emergency
withdrawal is made from
funds rolled over from a
non-457(b) retirement plan
into the 457(b) plan and
you are currently under age
59½ when you take this
withdrawal.
Notice to Non-Resident
Aliens: You may be subject
to Non-Resident Alien tax
withholding of 30% if you
are a citizen and resident
of a foreign country. If this
applies to you, you must
complete and submit form
W-8BEN to certify your
foreign status and request
a reduced treaty rate, if
applicable.
7. INCOME TAX WITHHOLDING
This withdrawal will be reported to the IRS as a distribution of income on Form 1099-R or Form 1042-S if you
are a Non-Resident Alien. Even if you elect NOT to withhold federal or state taxes, you are still responsible for
the tax liability resulting from this distribution.
TIAA will withhold at the default withholding rate of 10% for federal taxes unless you indicate otherwise below.
Federal Tax Withholding Instructions (Choose One)
Default Federal Withholding of 10%
Fixed percentage
% (must be greater than 10%)
No withholding; I will satisfy any tax obligation separately.
TIAA is required to withhold at the default state tax rate applicable for your state, unless you indicate
otherwise below.
State Tax Withholding Instructions (Choose One)
I want the following dollar amount withheld $
I want the following percentage withheld from the taxable portion of the payment
%
No withholding; I will satisfy any tax obligation separately.
If you reside in IA, ME, MA or NE, you may choose not to have state taxes withheld only if you elect not to
have federal taxes withheld. NOTE: Distributions to residents of IA for less than $6,000 will not be subject to
state income tax withholding.
To review your state tax withholding options, go to TIAA.org/forms, and scroll to Find tax forms.
TAEFT/OTCEMWTPUB
F11343 (10/16)
UNFORESEEABLE EMERGENCY WITHDRAWAL REQUEST
FROM AN ELIGIBLE 457(B) PLAN
Page 7 of 15
After completing this
unforeseeable emergency
withdrawal request form,
please attach and mail all
required documentation.
Please note: Include
ALL documents in ONE
package. Send only
copies. Documents and
attachments will not be
returned.
All documentation will be
reviewed and does not
guarantee approval of your
request. In some cases,
additional documentation
may be requested.
8. REQUIRED SUPPORTING DOCUMENTATION
Please write your name and TIAA and CREF plan number at the top of each attachment.
„„ Completed Unforeseeable Emergency Withdrawal Request Form
„„ Copies of tax documentation or other independent verification of spousal/dependent relationship
(if applicable)
„„ Copies of workers’ compensation or disability check stubs (if applicable)
„„ Copies of last paycheck stub (including spouse/dependent, if applicable) and/or other sources of income
(disability or workers’ compensation check stubs)
„„ Completed Asset and Income worksheet (Section 8A)
„„ Completed Expenses worksheet (Section 8B)
„„ Copies of loan denial letters from banks or other commercial lenders
„„
Illness or Accident
Loss of property due to casualty
Other similar extraordinary and
unforeseeable circumstances
arising as a result of events
beyond the control of the
participant or beneficiary
TAEFT/OTCEMWTPUB
F11343 (10/16)
Certified Physician’s statement — stating medical condition
„„ Medical bills from sudden illness or accident for you or one of
your dependents, showing amount required to pay
„„ Explanation of Benefits (EOB)
„„ Employer certification of no health insurance (if applicable)
„„ Proof of denial of insurance coverage
„„ Contractor’s estimate for repair due to catastrophic damages
„„ Statement from appropriate government agency or contractor
attesting to the cause of damage (earthquake, theft, etc.)
„„ Documentation similar to that listed above for illness, accident
or casualty loss depending on the type of emergency involved
„„ Copy of funeral expenses for a family member (defined as
a spouse or dependent — see Section 2 for definition of
dependent)
„„ Foreclosure or eviction notice regarding primary residence
(such a notice is not an automatic guarantee of approval of
an unforeseeable emergency withdrawal)
„„
UNFORESEEABLE EMERGENCY WITHDRAWAL REQUEST
FROM AN ELIGIBLE 457(B) PLAN
Page 8 of 15
Include the most recent
copy of checking account,
savings account and/or
credit union statement.
8 A. ASSET AND INCOME WORKSHEET
Participant Name
Plan Number
Liquid Assets
Fixed Assets
Savings:
Credit Union
$
Market Value of Residence$
Bank
$
Other Real Estate
$
Checking
$
Automobiles
$
Stocks/Bonds
$
Ownership Interest in:
Mutual Funds
$
Small Business
$
Cash Value of Life Ins.
$
Personal Property
$
Cash On-Hand
$
Other (explain below)
$
Other (explain below)
$
Other (explain below)
$
Other (explain below)
$
Other (explain below)
$
Other (explain below)
$
Other (explain below)
$
Other (explain below)
$
Total Liquid Assets
$
Total Fixed Assets
$
Explanation of “Other” listed above
Explanation of “Other” listed above
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TAEFT/OTCEMWTPUB
F11343 (10/16)
UNFORESEEABLE EMERGENCY WITHDRAWAL REQUEST
FROM AN ELIGIBLE 457(B) PLAN
Page 9 of 15
Include the most recent
copy of checking account,
savings account and/or
credit union statement.
8 A. ASSET AND INCOME WORKSHEET (CONTINUED)
Participant Name
Plan Number
Monthly Income
Your Salary
$
Spouse Salary
$
Alimony/Child Support
$
Other Income (explain below)
$
Total Gross Monthly Income
$
Minus Income Tax Withheld from Salary
$
Minus Deferral Amount (explain below)
$
Net Monthly Income
$
Explanations
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TAEFT/OTCEMWTPUB
F11343 (10/16)
UNFORESEEABLE EMERGENCY WITHDRAWAL REQUEST
FROM AN ELIGIBLE 457(B) PLAN
Page 10 of 15
Include the most recent
copy of checking account,
savings account and/or
credit union statement.
8 A. ASSET AND INCOME WORKSHEET (CONTINUED)
Participant Name
Plan Number
Other Retirement Assets
Plan Name
Does this plan allow for participant loans? No Yes
Have you exhausted all loan opportunities under the plan? No Yes
If No, how much is available as a loan from the plan? $
Does this plan allow you to take a withdrawal at this time? No Yes
If Yes, have you requested and received all available withdrawals from this plan? No Yes
No Yes
If you have not received all available withdrawals,
how much is available for withdrawal from the plan? $
Plan Name
Does this plan allow for participant loans? No Yes
Have you exhausted all loan opportunities under the plan? No Yes
If No, how much is available as a loan from the plan? $
Does this plan allow you to take a withdrawal at this time? No Yes
If Yes, have you requested and received all available withdrawals from this plan? If you have not received all available withdrawals,
how much is available for withdrawal from the plan? $
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TAEFT/OTCEMWTPUB
F11343 (10/16)
UNFORESEEABLE EMERGENCY WITHDRAWAL REQUEST
FROM AN ELIGIBLE 457(B) PLAN
Page 11 of 15
Include the most recent
copy of checking account,
savings account and/or
credit union statement.
8 A. ASSET AND INCOME WORKSHEET (CONTINUED)
Participant Name
Plan Number
Other Retirement Assets (CONTINUED)
IRA Provider
Does this account allow you to take a withdrawal at this time? No Yes
If Yes, have you requested and received all available withdrawals from this account? No Yes
No Yes
No Yes
If you have not received all available withdrawals,
how much is available for withdrawal from the account? $
IRA Provider
Does this account allow you to take a withdrawal at this time? No Yes
If Yes, have you requested and received all available withdrawals from this account? If you have not received all available withdrawals,
how much is available for withdrawal from the account? $
IRA Provider
Does this account allow you to take a withdrawal at this time? No Yes
If Yes, have you requested and received all available withdrawals from this account? If you have not received all available withdrawals,
how much is available for withdrawal from the account? $
If you have not exhausted all of your participant loan/withdrawal opportunities from any of these retirement
plans or IRAs, please explain why below.
TAEFT/OTCEMWTPUB
F11343 (10/16)
UNFORESEEABLE EMERGENCY WITHDRAWAL REQUEST
FROM AN ELIGIBLE 457(B) PLAN
Page 12 of 15
Attach copies of the most
recent statement for each
Loan or Charge Account.
8 B. EXPENSES WORKSHEET
Participant Name
Plan Number
Monthly Expenses (attach additional sheets if necessary. Include name and plan number on attachments)
Installment Loans
Creditor
Purpose
Date
Original
Balance
Present
Balance
Amount
Past Due
Monthly
Payment
Charge Cards and Accounts
Store or Bank
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TAEFT/OTCEMWTPUB
F11343 (10/16)
Credit Limit
Present Balance
Amount Past Due
Monthly Payment
UNFORESEEABLE EMERGENCY WITHDRAWAL REQUEST
FROM AN ELIGIBLE 457(B) PLAN
Page 13 of 15
Attach copies of the most
recent statement for each
Loan or Charge Account.
8 B. EXPENSES WORKSHEET (CONTINUED)
Participant Name
Plan Number
Monthly Expenses
Mortgage/Rent
$
Food$
Utilities and Telephone
$
Cable TV, Satellite Radio, Internet Access
$
Entertainment (sports, movies, restaurants, etc.)
$
Home Maintenance
$
Alimony/Child Support
$
Medical/Life Insurance
$
Vehicle Payments
$
Vehicle (gas, maintenance, insurance)
$
Medical (doctor, hospital, medications)
$
Other Expenses (please list)
$
$
$
Total Monthly Expenses$
Total Net Monthly Income
$
Minus Total Monthly Expenses
$
Total$
TAEFT/OTCEMWTPUB
F11343 (10/16)
UNFORESEEABLE EMERGENCY WITHDRAWAL REQUEST
FROM AN ELIGIBLE 457(B) PLAN
Page 14 of 15
9. PROVIDE PAYMENT INSTRUCTIONS
NOTE: If TIAA is unable to validate your bank account information for any reason, or you do not make a
selection below, we will automatically mail a check to your current address on file.
Please indicate where you would like us to send the money:
If you select direct deposit,
you will usually receive funds
within two (2) business
days once we have all the
required approvals and
documentation.
Direct Deposit to my bank account already on file:
You may fax copies of forms
and documents if you
request that we send the
payment via direct deposit
using banking information
we already have on file.
Otherwise, you must mail or
upload original documents
(not faxed copies) with this
form.
Direct Deposit to my new Checking or Savings Account:
Bank Name:
Account Number ending in:
Checking Account
OR
Savings Account
Provide documentation described in item A, B or C below.
A. Mail or upload a photo of an original voided check with this form. Starter checks, deposit slips and
third-party checks are not acceptable.
OR
B. Mail an original letter from your bank with the following information:
On bank letterhead, which includes address of bank
Name on your account
„„ Address on your account
„„ Bank/ABA routing number
„„ Account number
„„ Account type (Personal checking account or personal savings account)
„„ Signature of the financial institution’s representative. This signature must either be notarized by the
financial institution’s notary; or, it must be a signature guarantee including the stamp or seal from
the financial institution’s authorized representative.
„„ If any of the bullet points above are missing, we will send your payment to the current address on file.
„„
„„
OR
If you choose to receive
a check, we send it by
standard U.S. Mail and
it may take up to 8 – 10
business days for you to
receive it.
C. Mail or upload a Bank Generated Deposit Set Up Form from your bank that includes the following
information:
Name on your account
Address on your account
„„ Bank/ABA routing number
„„ Account number
„„ Account type (Personal checking account or personal savings account)
„„
„„
Mail a check to my current address on file.
Note: To ensure your account is secure, we can’t send a check to a mailing address that has changed in
the last 14 days. So, if you’re requesting that we send the payment to your mailing address and you’ve
recently changed it, we may not be able to process your current request. Call us so we can discuss some
of your options for completing your request.
TAEFT/OTCEMWTPUB
F11343 (10/16)
UNFORESEEABLE EMERGENCY WITHDRAWAL REQUEST
FROM AN ELIGIBLE 457(B) PLAN
Page 15 of 15
10. AUTHORIZE YOUR REQUEST
Please read and sign
where indicated.
I understand that TIAA may rely conclusively on these certifications in processing the requested benefits above and
that, in the case of any conflicting information, TIAA is entitled to rely exclusively on the information contained in this
unforeseeable emergency withdrawal request.
I certify that I am unable to obtain the amount needed from other reasonably available resources and have already
reduced the amount of my hardship by other resources that are reasonably available to me, including, but not limited to (a)
reimbursement or compensation by insurance or otherwise; (b) liquidation of my assets as long as liquidation of such assets
would not itself cause hardship; (c) cessation of plan deferrals; and (d) other reasonably available financial resources.
I agree to sign any authorizations necessary for any of my medical providers to release information about my medical
history or condition related to my request for an unforeseeable emergency withdrawal. I hereby authorize TIAA, its
authorized representatives and the Plan Sponsor to use my personal information, including personal medical information,
for the purpose of processing my unforeseeable emergency withdrawal request. Except where ordered by a court of
law or by a governmental agency, TIAA, its authorized representatives, and Plan Sponsor shall not release any personal
information used to process my request to any party without my prior written approval.
I certify that there is no pending Qualified Domestic Relations Order (QDRO), a court judgement, decree or order relating
to the provision of child support, alimony, or marital property rights to a spouse, former spouse, child or other dependent
with respect to the requested withdrawal amount. I understand that TIAA reserves the right to directly or through a third
party recover any payments made in excess of amounts to which I am entitled under the terms of the plan, regardless of
the method of payment.
I understand that I will be responsible for providing evidence to the IRS, if required, to verify my distribution reason. I agree
to maintain supporting documentation for this unforeseeable emergency withdrawal request and make such documentation
available to the IRS, my employer, or TIAA as may be necessary to verify the qualification of the distribution requested.
I understand that even if I decide not to have federal/state income tax withheld, I am still liable for payment of federal/
state income tax for any taxable portion of this payment. I may be subject to tax penalties under the estimated tax
payment rules if my payment of estimated tax and withholding, if any, is not sufficient to cover my tax liability.
I hereby certify, under penalty of perjury, that the information in this application is accurate and complete. It is furnished
solely for confidential use in determining eligibility for unforeseeable emergency withdrawal under the Deferred
Compensation Plan. I understand that this information is provided in accordance with the Internal Revenue Code and
applicable Treasury regulations.
Submit this request
form and copies of all
applicable documents by
mail. Carefully read the
“Required Documentation
in Section 8”.
For your protection, TIAA may require additional verification of your identity before accepting your transaction as in
good order. You agree that your transaction will be valued as of the market close on the business day that all of steps
necessary to verify your identity and the transaction to be in good order have been completed. You also agree that in the
event these steps are completed after the market close on a business day, then your transaction will be valued as of the
market close on the next business day. The amount of money that you receive will depend on the share or unit price on
the day on which your transaction is deemed to be in good order. Due to market fluctuations, the price your shares or
units ultimately receive could be less than the share or unit price when you initiated this transaction. It is also possible
that if we are unable to reach you to verify this transaction it may result in the transaction being canceled.
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; and (4) The
FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.
Note: There are no FATCA code entries on this form, so please disregard item 4.
Please sign your full legal
name with suffix, if
applicable, using black
or dark blue ink.

The Internal Revenue Service does not require your consent to any provision of this document other than the
certifications required to avoid backup withholding.
Your Signature
Name (please print)
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UNFORESEEABLE EMERGENCY WITHDRAWAL REQUEST
FROM AN ELIGIBLE 457(B) PLAN
RETURN COMPLETED FORM TO:
STANDARD MAIL:
OVERNIGHT: TIAA
TIAA
P.O. Box 1259
8500 Andrew Carnegie Blvd.
Charlotte, NC 28201-1259
Charlotte, NC 28262
(Sorry, we cannot accept faxed forms.)
FRAUD WARNING
FOR YOUR PROTECTION, WE PROVIDE THIS NOTICE/WARNING REQUIRED BY MANY STATES
This notice/warning does not apply in New York.
Any person who, knowingly and with intent to defraud any insurance company or other person, files
an application for insurance or a statement of claim for insurance benefits containing materially false
information or conceals, for the purpose of misleading, information concerning any fact material thereto,
commits a fraudulent insurance act, which is a crime and may be subject to criminal penalties, including
confinement in prison, and civil penalties. Such action may entitle the insurance company to deny or void
coverage or benefits.
Colorado residents, please note: Any insurance company or agent of an insurance company who knowingly
provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of
defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable
from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of
Regulatory Agencies.
Virginia and Washington, DC residents, please note: Any person who knowingly presents a false or
fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application
for insurance is guilty of a crime and may be subject to fines and confinement in prison.
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