State Form 51623 – Fill Out and Use This PDF

Step 1

Employee Name

Social Security Number

Current Date

Mailing Address

Date of Birth

Home Phone Number

(Street)

Marital Status

Business Phone Number

(City,State,Zip)

Single

Married

Step 2

Hardship Withdrawal Provisions

The Plan permits hardship withdrawals only to the extent a participant demonstrates to the satisfaction of the Plan Committee that the reason for

the withdrawal complies with the applicable requirements under the Internal Revenue Code and that such hardship is due to an unforeseeable

emergency. As a general rule, Plan money cannot be distributed for an event within your control. Thus, tuition expenses, down payment for a

house, or ordinary medical expenses are not considered unforeseeable emergencies.

We recommend that you consult with your financial advisor regarding this withdrawal. If you have any questions about unforeseeable emergency

withdrawals please contact SchoolsFirst Federal Credit Union at 800-462-8328 ext. 4727.

Amount Available for Withdrawal

If you have a qualified unforeseeable emergency, you may withdraw the amount necessary to meet the need created by the emergency. Payment

will not be made to the extent that the financial hardship may be satisfied through cessation of deferrals, insurance, other reimbursement, or

liquidation of other assets to the extent such liquidation would not itself cause severe financial hardship.

Step 3

Nature and Description of Hardship

In the space provided below, indicate the nature of the unforeseeable emergency for which you are requesting a withdrawal from the Plan. You

may attach additional pages if more space is needed. Attach appropriate documentation to provide evidence that you have a financial hardship.

As part of the review process, the Plan Committee may require additional proof of your financial hardship.

Severe financial hardship to the participant resulting from a sudden and unexpected illness or accident of the participant or beneficiary, the

participant or beneficiary's spouse, or the participant or beneficiary's dependent.

Loss of the participant's or beneficiary's property because of casualty or other extraordinary and unforeseeable circumstances arising as

result of events beyond the control of the participant or beneficiary.

Step 4

Hardship Amount

Nationwide

Amount $_______________________

Other

Amount $_______________________

Step 5

Spousal Consent

Federal laws require that the Plan Committee obtain adequate signature verification when certain benefit payments are made under qualified

plans; therefore, if you are legally married and the amount of the distribution is over $5,000, both you and your spouse must sign this hardship

withdrawal application. Your spouse's signature must be witnessed by a Plan representative or a notary public.

Spouse Signature

Date

Notary Public or Plan Administrator

Date

Step 6

Certification of Hardship

I have read and I understand this application for unforeseeable emergency withdrawal. I certify that I do not have any other source of assets which

can be liquidated to meet the financial hardship outlined above. I consent to the immediate distribution of the withdrawal to me in a single sum

cash payment. I declare under penalty of perjury under the laws of the state of California that the information I have supplied on this application for

the withdrawal is true and complete in all respects.

Employee Signature (required)

Date

Signature Guarantee

Date

SchoolsFirst

Federal

Credit Union

Office Use

Only

SchoolsFirst Federal Credit Union Authorized Signature (required)

Date

(3/08)

Return this form to: SchoolsFirst Federal Credit Union - Member Retirement Services

P.O. Box 11547