CSU Tax Sheltered Annuity

(To be completed by employee and returned to the campus with the 403(b) vendor withdrawal request form)

I hereby certify that I have incurred a financial hardship so as to need a withdrawal of the amount of $__________________ based on the following need (check one):

  Costs related to unreimbursed medical expenses (including the past 12 months, these costs exceed $____________).

  Costs related to purchase of a principal residence (excluding mortgage payments).  These costs will exceed $__________.

  Payment of tuition and related educational fees as well as room and board expenses for the next 12 months of postsecondary education for myself, my spouse or dependents, which are estimated to exceed $____________.

   Payment necessary to prevent my eviction from my principal residence or to avoid foreclosure on the mortgage on that residence, the cost of which shall exceed $__________.

I further certify that the withdrawal amount designated on the attached 403(b) distribution form (which form is from your 403(b) plan, not the CSU) is necessary to meet my financial need created by the hardship to the extent that no other funds are reasonably available.  Moreover, I acknowledge that the amount necessary to meet my financial need may include the amount of any federal, state or local income taxes or penalties reasonably anticipated to result from my withdrawal.  Furthermore, I have determined that the amount of my financial hardship cannot be satisfied by any other distributions and nontaxable loans currently available to me under any benefit plans maintained by my employer, the Trustees of the California State University, an agency of the State of California acting in its higher education capacity.

I understand that I am responsible for retaining the original documentation necessary to verify that a financial hardship exists at the time I make this request for a financial hardship 403(b) Plan distribution.  I acknowledge that, upon my receipt of the hardship distribution, I will instruct my CSU payroll department to suspend for a period of 6 months any elective contributions and employee contribution to any plan maintained by my employer.  I understand that I cannot roll over the hardship distribution to any other tax-deferred retirement plan or individual Retirement Account or Annuity (IRA).  Further, I indemnify and hold the CSU and my tax shelter annuity/mutual fund provider harmless from any losses or financial obligation, which may arise by reason of processing such financial hardship request with respect to my 403(b) arrangement.

I certify under penalty of perjury that all of the foregoing statements are true and correct.  This statement is made in ____________________, California.

_____________________

* Listing of the Social Security Number (SSN) is required since the CSU uses the SSN as an employee identification of its computerized payroll and benefit system, which must be used in this transaction.

November 2002