unforeseeable emergency withdrawal request from

INSTRUCTIONS

TAEFTF11343 (1/12)

To check the status of your request or ask any questions:

Call 800 842-2252

Monday — Friday 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 consequences as 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 therefore urged to consider this request carefully.

The IRS defines unforeseeable emergency as a severe financial hardship to the participant or 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 distributable amounts 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.

CONTINUED ON NEXT PAGE

UNFORESEEABLE EMERGENCY WITHDRAWAL REQUEST FROM A NONQUALIFIED DEFERRED COMPENSATION PLAN

INSTRUCTIONS

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 unforesee-able 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 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)■■ Marital separation or divorce■■ Legal fees■■ Credit card debt■■ Purchase or repair of an automobile■■ Purchase or repair of a furnace or air conditioner■■ 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 damage not covered by

insurance due to casualty loss from natural disasters (i.e., 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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F11343-0112-01

Print in upper case using black or dark blue ink and provide all information requested.

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 form W-8BEN, go to www.tiaa-cref.org/forms, under General Tax Forms.

* 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 benefi-ciary status. Examples include: federal tax return showing depen-dent 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.

Page 1 of 15

1. PROVIDE ACCOUNT HOLDER PERSONAL AND ACCOUNT INFORMATION

First Name Middle Initial

Last Name

Social Security Number/Taxpayer Identification Number Date of Birth (mm/dd/yyyy)

/ /

Daytime Telephone Number Extension

— —

State of Legal Residence (if outside the U.S., write in Country of Residence) Citizenship (if not U.S.)

TIAA Number CREF Number

Plan Name (Contributing Employer’s Plan)

Plan Number Sub Plan Number

2. DEPENDENT/BENEFICIARY INFORMATIONThis 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).


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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 you need more space, please continue on a separate page. Be sure to write your name and TIAA-CREF plan number on all attachments.

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.

Page 2 of 15

2. DEPENDENT/BENEFICIARY INFORMATION (CONTINUED)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.

3. ALTERNATE FUNDING VALIDATIONCan this hardship be completely or partially relieved through the following options:

Will you be reimbursed or compensated by insurance?

No Yes

If Yes, please identify source of reimbursement:

Have you sold or otherwise liquidated any assets?

No 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.

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If you need more space, please continue on a separate page. Be sure to include your name and plan number on the attachment.

Page 3 of 15

4. DESCRIPTION OF EMERGENCY

Have you applied for loans from credit unions, banks or other commercial sources to cover the financial need?

Amount Source

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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Documentation must be provided that corresponds to the Amount Needed for Emergency.

Page 4 of 15

5. DISTRIBUTION REQUESTThe 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-CREF 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-CREF can only increase payments for income tax withholding if you elect to withhold taxes (you may indicate your tax withholding preferences in Section 6).

Yes No (if no selection is made, the withdrawal will not be increased to cover taxes)

Explain why you are requesting this particular amount and how it will solve your financial problem:

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

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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.

Page 5 of 15

6. INCOME TAX WITHHOLDING

This withdrawal will be reported to the IRS as a distribution of income on Form W-2, 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-CREF will withhold at the default withholding rate of 10% for federal taxes unless you indicate otherwise below.

Federal 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 %

DO NOT withhold

TIAA-CREF 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 %

DO NOT withhold

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 www.tiaa-cref.org/forms under General Tax Forms.

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F11343-0112-06

After completing this unforeseeable emergency withdrawal request form, please attach all required documentation to the form and mail to the address indicated below.

Please write your name and TIAA-CREF plan number on all attachments.

Please Note: Include ALL documents in ONE package. Send only copies. Documents and attachments will not be returned.

Mail completed form and materials to: TIAA-CREF P.O. Box 1259 Charlotte, NC 28201-1259

All documentation will be reviewed and does not guarantee approval of your request. In some cases, additional documentation may be requested.

Page 6 of 15

7. REQUIRED SUPPORTING DOCUMENTATION■■ Please write your name and TIAA-CREF plan number at the top of each attachment. ■■ Completed unforeseeable emergency withdrawal 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 7A) ■■ Completed Expenses worksheet (Section 7B) ■■ Copies of loan denial letters from banks or other commercial lenders

Illness or Accident ■■ 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)

Loss of property due to casualty ■■ 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.)

Other similar extraordinary and unforeseeable circumstances arising as a result of events beyond the control of the participant or beneficiary

■■ 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)

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F11343-0112-07

Include the most recent copy of checking account, savings account and/or credit union statement.

Page 7 of 15

7A. ASSET AND INCOME WORKSHEET

Participant Name Plan Number

Explanation of “Other” listed above Explanation of “Other” listed above


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) $

Total Liquid Assets $ Total Fixed Assets $

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7A. ASSET AND INCOME WORKSHEET (CONTINUED)


Explanations


Include copy of most recent paycheck stub. Where applicable, include copies of spouse’s paycheck stub, disability check stub, or worker’s compensation check stub.

Page 8 of 15

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 $

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F11343-0112-09

List all retirement assets (401(k), 403(b), etc.). Include personal retirement accounts such as IRA.

If you need more space, please continue on a separate page. Be sure to write your name and TIAA-CREF plan number on the attachment.

Page 9 of 15



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

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? No Yes

If you have not received all available withdrawals, how much is available for withdrawal from the plan? $


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If you need more space,please continue on a separate page. Be sure to write your name and TIAA-CREF plan number on the attachment.

Page 10 of 15



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

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 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 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.

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Attach copies of the most recent statement for each Loan or Charge Account.

Page 11 of 15

7B. EXPENSES WORKSHEET


Monthly Expenses (attach additional sheets if necessary. Include name and plan number on attachments)

Installment Loans

Charge Cards and Accounts


Creditor Purpose DateOriginal Balance

Present Balance

Amount Past Due

Monthly Payment

Store or Bank Credit LimitPresent Balance

Amount Past Due

Monthly Payment

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Page 12 of 15

7B. EXPENSES WORKSHEET (CONTINUED)


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 $

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If your banking instructions are invalid TIAA-CREF will send a check to your address on �le.

Your bank routing number is 9 digits and is usually on the bottom left of your checks, before your account number. It may take your bank 24 to 72 hours to make your funds available.

You must provide your personal account information ONLY. Direct Deposit is not permitted to a third-party account.

Page 13 of 15

8. DELIVERY INSTRUCTIONS (CHOOSE ONE)

Tell us how you want to receive your money in the event your request is approved.

OPTION 1: Send my check to my address of record.

OPTION 2: Use banking information already on file.

OPTION 3: Direct Deposit to my checking account

Check here and complete information below. You must provide an original voided check and mail it to TIAA-CREF with the completed form.

OPTION 4: Direct Deposit to my savings account

Check here and complete information below. You must provide us with either an original voided check or a letter from your bank. If your savings account has check writing privileges, you may send us an original voided check. If your savings account does not have check writing privileges, you must send us an original letter from your bank. The letter must be on bank letterhead and include:

a. Name on your account b. Address on your account c. Bank/ ABA routing number d. Account number and account type (i.e. Money Market, Savings, etc.) e. Bank Signature Guarantee, including bank stamp or seal, from authorized bank personnel

Bank’s Name

Street Address or P.O. Box for Funds Transfer

City State Zip Code

Bank Contact Phone Number Extension

— —

Bank Routing Number Account Number

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Please read and sign where indicated.

Submit this request

applicable documents

mail. Carefully read the “Required Documentation” in Section 7.

Page 14 of 15

9. AUTHORIZE YOUR REQUEST

I understand that TIAA-CREF may rely conclusively on these certi�cations in processing the requested bene�ts above and that, in the case of any con�icting information, TIAA-CREF 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 �nancial 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.

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-CREF 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-CREF as may be necessary to verify the quali�cation 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 suf�cient 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.

Your Signature Today’s Date (mm/dd/yyyy)

/ / 20

1. The number shown on this form is my correct Social Security number/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.

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Page 15 of 15

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 claim-ant 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.

TAEFTF11343 (1/12)
