GA Plan Administrators - Forms - 457 Plan Hardship Distribution Request Form

	457 Plan Hardship Distribution Request Form Please provide the following information regarding your withdrawal request. When finished, click Submit. For more information regarding distributions from 457 plans, please see When Can I Take a Distribution from My 457?.
	Date
	Name
	E-mail Address
	Social Security No.	- -
	Phone Number
	Employer Name
	Withdrawal Amount
	Reason for the Withdrawal: Verification for the reason chosen needs to be faxed to "Distribution Request" at 513.357.3199. Failure to provide verification can delay the processing of your request. Unforeseeable Emergency: My unforeseeable emergency is a severe financial hardship resulting from (choose one): Illness or accident of participant, beneficiary, spouse, or dependents. My loss of property due to casualty. Other extraordinary and unforeseeable circumstances beyond my control (please describe):