Step 1 of 3: Supply Information | Step 2 of 3: Confirm Entries | Step 3 of 3: Submission Confirmation

Please Note: This form version MUST be completed online. For a downloadable version to submit via mail or fax, please click here.
  • Please supply the information requested below.
  • Read all agreements on this form before submitting.
  • Fields having an asterisk notation are required.
IMPORTANT NOTICE: Before You Sign, Read All Information on this form:
Further information regarding IRS regulations relating to this subject can be found at the IRS website or in the IRS Publication 571.

Current Employer:

PLEASE NOTE: Unforeseeable Emergency disbursements may be possible ONLY against your CURRENT employer's plan. For disbursement options from plans sponsored by previous employers, please contact Tax Deferred Solutions.

*Employer Name:
New Haven Unified School District
BEFORE CONTINUING: Please verify that you have selected the correct Employer. If the Employer shown is not correct, please return to the main page and select your correct Employer.

Employee Information:

*Last Name:    *First Name:    MI: 
Maiden/Former Name:   
* Address:
* City: * State:   * Zip:
* Phone Alternate Phone
* Email * Re-enter Email:
*SS#: (9 digits, no dashes or spaces) * Date of Birth: (MM/DD/YYYY)
Date of Separation: (MM/DD/YYYY)

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:
*Service Provider Company:
If other, please supply company name here:
Account #:
*Amount Requested:

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:

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.
Costs directly related to the purchase of a principal residence for the employee (excluding mortgage payments);
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;
Payment necessary to prevent eviction of the employee from the employee's principal residence or foreclosure on the mortgage on that residence;
Payment of funeral expenses for the employee's spouse, dependent, or primary beneficiary under the 457 plan;
Certain expenses relating to the repair of damage to the employee's principal residence.
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.

*Date Unforeseeable Emergency First Occurred:   

Alternative Measures:

Please answer the following questions:

* 1. Are there distributions available to you under the plan or any other plans maintained by your employer that will alleviate the Unforeseeable Emergency?
* 2. Can you receive reimbursement from insurance or other sources to pay these expenses?
* 3. Can you secure a commercial loan to pay these expenses?
* 4. Can you liquidate assets to pay these expenses?



I certify that this request is for an unforeseen emergency that cannot be reimbursement from insurance or another source, and the amount requested is not more than necessary to satisfy the need.

*Re-enter Social Security # to verify:

Additional instructions will appear on the next screen    

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