4.1443 Request for emergency withdrawal- Form.
(a) If a participant incurs an unforeseeable emergency as defined in 4.1444, the participant may apply for an emergency withdrawal by filing with the administrator a completed emergency withdrawal request form prescribed by the board, attaching evidence in support of the request. Additional evidence may be required by the board as necessary to dispose of the request.
(b) A participant requesting an emergency withdrawal shall enter on the form the following:
(1) identifying information, including name, home address, employing department, and work telephone number;
(2) list of participant’s assets;
(3) specification of unforeseeable emergency;
(4) detail of costs incurred or to be incurred;
(5) whether the withdrawal results from an emergency affecting someone other than participant and, if so, whether that person is the participant’s dependent;
(6) amounts not payable by other sources;
(7) amounts necessary to satisfy the emergency; and
(8) signature authorizing proper withholding of taxes and certifying the information is true and correct to the best of the participant’s knowledge and belief.History: Rule 11-87, eff 17 Jun 87.