your death benefit will be reduced

For Every Action There Is a Reaction Your Three-Point Checklist for Partial Withdrawals

While your annuity contract allows for partial withdrawals to help meet short-term objectives, it is important to understand that withdrawing funds from your contract may also affect your long-term financial goals. Below is a checklist of considerations to review with your MassMutual financial services representative as you decide on the details of your partial withdrawal.

Your Death Benefit Will Be Reduced An annuity’s death benefit is a critical, but often overlooked, contract feature that provides a value to pass on to your beneficiaries in the event of your death. In some cases, your death benefit may even exceed your contract’s cash value, meaning that your beneficiaries would be entitled to more than what the contract’s underlying investments are currently worth.

Partial withdrawals will reduce your death benefit. Depending on the terms of your contract, the reduction may be greater when the value of your contract investment choices is lower due to market performance or other variables. We suggest contacting your MassMutual financial services representative to discuss the implications that a partial withdrawal will have on your death benefit.

You May Have Tax Implications If you take a partial withdrawal of your annuity contract, you may be subject to both federal and state income tax. In addition, if you are under 59½ years old, you may be subject to a 10% tax penalty for premature distribution of your annuity. This penalty would be in addition to any other applicable federal or state income tax. For additional information, you may want to consult your tax advisor.

You May Incur Surrender Charges If your annuity contract has a contingent deferred sales/surrender charge and you are still within the surrender charge period as outlined in your contract, you will be subject to a charge if you withdraw more than your current allowable free withdrawal amount. It may be in your best interest to defer taking a partial withdrawal until your surrender charge is lessened.

If you have questions or would like more information, please call your MassMutual financial services representative or our Annuity Service Center at 1-800-272-2216, Monday through Friday 8 a.m. to 8 p.m. Eastern Time.

Massachusetts Mutual Life Insurance Company (MassMutual), 1295 State Street, Springfield, MA 01111-0001 and its subsidiaries: C.M. Life Insurance Company and MML Bay State Life Insurance Company, 100 Bright Meadow Boulevard, Enfield, Connecticut 06082-1981.

Minimum Withdrawal Amounts and Contract Balances

The following chart contains important information for your reference as you complete the partial withdrawal form.

Minimum allowable withdrawal

Minimum balance

required to keep contract

open

Minimum balance to initiate Systematic Withdrawal

Program

CM Windows® $1,000 $5,000 n/a

Flex Extra $100 $500 $10,000

Flex-Annuity $100 $600 n/aFoundation

Annuity $100 $500 $10,000

LifeTrust $100 $1,000 $10,000MassMutual

Artistry $100 $600 $25,000 (IRA) $10,000 (TSA*)

MassMutual Equity EdgeSM $100 $10,000 n/a

MassMutual EvolutionSM ** $100 $2,000 $5,000

MassMutual Odyssey®

$100 (Specified Dollar Amount)

$25 (Interest Only) $2,000 $2,000 (Specified Dollar Amount)

$15,000 (Interest Only)

MassMutual Odyssey PlusSM $250 $10,000 $10,000 (Specified Dollar

Amount) No minimum (Interest Only)

MassMutual Odyssey SelectSM

$250 (13 per contract year limit) $3,000 n/a

MassMutual Stable VoyageSM

$250 (13 per contract year limit) $7,500 n/a

MassMutual Transitions® ** $100 $2,000 $25,000

MassMutual Transitions SelectSM **

$100 $2,000 $5,000 (IRA/Non-Qualified) $10,000 (TSA*)

Panorama® $100 $250 $25,000Panorama Passage® $250 $2,000 $25,000

Panorama Plus $100 $250 $25,000

Panorama Premier $100 $5,000

(Non-Qualified) $2,000 (Qualified)

$25,000

* Tax Sheltered Annuity** If the GMAB or GMIB feature is selected, please refer to the appropriate product prospectus for the

impact of withdrawals on these benefits.

*** Written requests to bring the contract to $0 must be on a full withdrawal request form.

© 2010 Massachusetts Mutual Life Insurance Company. All rights reserved. www.massmutual.com.

AN7696 0113

of 13 Partial Withdrawal & Systematic Withdrawal Request FR1202-AN 0121

Partial Withdrawal & Systematic Withdrawal Request

Use this form to request a partial withdrawal or to elect or change a systematic withdrawal election on your contract. This form can be used for all deferred annuity contracts with the exception of:

• Tax Sheltered Annuities, Keogh/H.R.10 and Individual Qualified Employee Benefit Plans – use form FR1149;• Contracts participating in MassMutual Guaranteed Income Plus 5, MassMutual Guaranteed Income Plus 6 or MassMutual Lifetime

Payment PlusSM) – use form F9700;• Transitions Select Contracts with MassMutual Lifetime Income Protector use form FR1204. or

• Required Minimum Distribution requests – use form F6695. After reading section H – Disclosures, complete all sections of this form, unless otherwise indicated, sign and return. The release of contract values may affect the guaranteed elements, non-guaranteed elements, cash or surrender value of the contract from which the values are released. Some requests available on this form may be made over the phone by contacting our Service Center at 1-800-272-2216.

A Contract Information � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �1. Contract number:

2. Owner full legal name:

3. Taxpayer Identification Number (SSN/ITIN/EIN):

4. Phone number: ( ) - Extension: Home Work Mobile

5. Email address:

6. Joint Owner full legal name (if applicable):

7. Joint Owner phone number: ( ) - Extension: Home Work Mobile

8. Joint Owner email address:

9. *Plan Contact name (First, MI, Last, Suffix):

10. *Plan Contact phone number: ( ) - Extension: Home Work Mobile* Complete for Governmental 457(b) Deferred Compensation, Qualified Employee Benefit (QEB) and Non-Qualified Deferred Compensation Plans.

Complete questions 11 -13 for Governmental 457(b) Deferred Compensation Plan distributions paid to the Plan Participant. Otherwise, skip to section B – One-Time Partial Withdrawal.

11. Plan Participant/Annuitant name:

12. Annuitant Taxpayer Identification Number (SSN/ITIN):

13. Distribution eligibility reason (Select one):

Attainment of age 70½

Severance from employment Severance Date (mm/dd/yyyy): _______/________/_____________

Plan termination

Unforeseen emergency

Qualified birth or adoption distribution


B One-Time Partial Withdrawal � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �Complete this section to request a one-time partial withdrawal from your contract. Otherwise, skip to section C – Systematic Withdrawal Program (SWP).• If you are currently receiving distributions intended to qualify for the substantially equal periodic payment (SEPP) exception described in

Internal Revenue Code (IRC) section 72(t) or 72(q), adverse tax consequences may apply. Refer to section H – Disclosures for further information.

• Withdrawals may be subject to a contingent deferred sales charge (CDSC) or surrender charge. Refer to the prospectus for variable annuities or your contract for details on charges.

• For variable annuities: Your withdrawal is effective on the business day we receive the request in good order at our Service Center; unless you request a specific withdrawal date. If we receive your withdrawal request at our Service Center on a non business day or after the close of business, your withdrawal will be effective on the next business day.

• For variable annuities: Your withdrawal will be taken on a pro rata basis from your current investment elections, unless you specify otherwise. If you wish to make your withdrawal fund-specific, attach instructions. Fund-specific allocations must equal 100%. (Not available for MassMutual Equity Edge, MassMutual Evolution, MassMutual Transitions Select or any fixed annuity contracts.)

Process my fund-specific withdrawal request according to the attached sheet I have provided. Fund-specific allocations must equal 100%

Future Withdrawal Processing Date (Complete this section only to elect a future processing date)

A withdrawal request date cannot exceed 30 days in the future.

Specific date (mm/dd/yyyy): For Equity Edge contracts only: If choosing to take a withdrawal from your Equity Edge contract, your withdrawal may be subject to a CDSC and will result in an adjustment to your principal protection benefit if the withdrawal is not effective on the benefit expiration date.

Check box if you would like the withdrawal from your Equity Edge Contract to be effective on the benefit expiration date.

One-Time Partial Withdrawal Election

1. Withdrawal Option (Select one):

Withdrawals free of CDSC/surrender charge: Partial withdrawal of the contract value that is free of CDSC (surrender penalty) (If the entire contract value is free of CDSC (surrender

penalty) we will process the withdrawal for the maximum amount available that will keep the contract open.) Return of excess contributions $ for tax year (Excess contributions withdrawals may

include adjustments for gain or loss attributable to the contribution.) Refer to section H – Disclosures for further information.

Withdrawals that may be subject to CDSC/surrender charge: Withdraw the maximum amount while keeping the contract active Withdraw amount of $ or % of contract value (If amount specified is more than the

amount available, the request will be processed for the maximum amount available.)

Withdrawal Method

2. Method (Select one):

Gross of any applicable CDSC/surrender charge and/or tax withholding (Default)

Net of any applicable CDSC/surrender charge and/or tax withholding (Only available when dollar or percentage withdrawal is indicated. Not available for Equity Edge.)

Refer to section H – Disclosures for further information.

Optional Provisions/Waivers

Complete this section to exercise your contract’s Nursing Home and Hospital Benefit Waiver and/or Terminal Illness Withdrawal Benefit.

3. Waiver type (Select all that apply):

Nursing Home and Hospital Benefit Waiver. To request a waiver of the CDSC/surrender charge, also complete the Nursing Home and Hospital Benefit Waiver form F6940.

Terminal Illness Withdrawal Benefit. To request a waiver of the CDSC/surrender charge, also complete the Terminal Illness Withdrawal Benefit form FR1034.


C Systematic Withdrawal Program (SWP) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �Complete this section to elect or change a systematic withdrawal from your contract. Not available for Plan-owned Qualified Employee Benefit Plans, Non-Qualified Deferred Compensation Plans, and Corporate Owned Non-Qualified contracts.• SWP is not available for tax-free direct rollovers, trustee-to-trustee transfers, or 1035 exchanges.• SWP is not available for Flex Series contracts, MassMutual Equity Edge, or Fixed Annuity products other than MassMutual Odyssey.• Changes to or termination of this program can be made at any time by contacting the Service Center.• Withdrawals may be subject to a contingent deferred sales charge (CDSC) or surrender charge. Refer to the prospectus for variable annuities

or your contract for details on charges.• SWP will be canceled if as a result of the transaction, your contract value would fall below the minimum contract balance, unless your SWP

qualifies for the substantially equal periodic payment exception described in section 72(t) or 72(q) of the Internal Revenue Code. In addition, your SWP will end if your value in a selected fund or the fixed account is insufficient to complete the withdrawal.

• Before establishing a SWP that is intended to qualify as a series of substantially equal periodic payments (SEPP) under IRC section 72(t) or 72(q), you should contact the Service Center to obtain a quote, since later modifications may subject all prior payments to a 10% penalty tax, plus interest.

• If your contract is currently on a SWP that is intended to qualify as SEPP under section 72(t) or 72(q) of the IRC, a change may be considered an impermissible modification and may subject all of your prior payments to the 10% penalty, plus interest.

• For variable annuities- Unless you direct us otherwise, your withdrawal will be taken on a pro rata basis from your current investment elections. Check below if you wish to make your withdrawal fund specific. (Not available for MassMutual Evolution, MassMutual Transitions Select or any fixed annuity contracts) Process my fund-specific withdrawal request according to the attached sheet I have provided. Fund-specific allocations must equal 100%.

SWP Instructions

1. (Select one): Set up new SWP Change existing SWP Only change existing SWP payment from check to EFT (Also complete section D2.)

SWP Processing Date (Complete this section to elect the frequency, start date and duration)

If no start date is provided the SWP will start within 5 business days of the date we receive this Form in good order at our Service Center. Start and stop dates cannot exceed the 28th of the month.2. Frequency (Select one): Monthly Quarterly Semi-annually Annually

3. Start date (mm/dd/yyyy):

Duration (Optional): *Stop on (mm/dd/yyyy): or after processing (Specify number): withdrawals* If the SWP is intended to qualify as a SEPP under IRC section 72(t) or 72(q), you may not select a stop date prior to your attaining age 59

1/2 or the expiration of 5 years, whichever is later.Flex contracts- SWP can only run on the 7th, 12th, 17th, 22nd and 27th. If a different date is chosen, your SWP will run on the next available run date.

Systematic Withdrawal Election (For SEPP skip to question 6)

4. SWP election (Select one): Systematic withdrawal in the amount of $ Systematic withdrawal in the amount of % of contract value (MassMutual Odyssey Select and MassMutual Stable

Voyage only) Maximum free amount systematic withdrawal (MassMutual Odyssey Select, MassMutual Stable Voyage, and Flex Extra only) Interest only systematic withdrawal (MassMutual Odyssey, MassMutual Odyssey Plus, MassMutual Odyssey Select, and MassMutual

Stable Voyage only) Make 1st withdrawal for interest available since inception Make 1st withdrawal for interest available for selected frequency (Default)

Systematic Withdrawal Method For 72(t) or 72(q) skip to question 6.

5. Method (Select one): Gross of any applicable CDSC/surrender charge and/or tax withholding (Default) Net of any applicable CDSC/surrender charge and/or tax withholding (Only available when dollar or percentage withdrawal is indicated.)


C Systematic Withdrawal Program (SWP) continued • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •Substantially Equal Period Payments (SEPP) (Not available for Stable Voyage contracts.}

CONSULT YOUR TAX ADVISOR BEFORE PROCEEDING6. Check here if these distributions are intended to qualify for the substantially equal periodic payment exception (SEPP) de-

scribed in section 72(t) or 72(q) of the IRC. If you elect 72(t) or 72(q) SEPP payments, a partial withdrawal or additional payments into your contract may be considered an impermissible modification and may subject all of your prior payments to the 10% penalty, plus interest. If your distributions qualify as a SEPP, the 10% premature distribution penalty will not apply to the taxable portion of the distribution however; CDSC/surrender charges may apply. Once you begin 72(t) or 72(q) SEPP payments, an alteration of the payment schedule will subject you to a 10% penalty tax, plus interest, if it occurs before the expiration of 5 years or before you have reached age 59 ½, whichever occurs later. Distributions taken as a SEPP under section 72(t) or 72(q) will be made net of any applicable CDSC/surrender charge and gross of any tax withholding.

7. Calculation method used (Select one): Annuity Factor Method Amortization Method RMD Method (Life Expectancy)

D Distribution Instructions � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �UPS Overnight Request. Send withdrawal via UPS Priority. Only available for one-time partial withdrawal. (The carrier charges a fee and cannot ship to a PO Box. If information below is not complete, the check will be mailed through regular U.S. Postal Service.)

UPS account number: UPS account name: Associated Zip/Postal Code: Email delivery notification (If yes, Owner’s email address indicated in section A – Contract Information will be used): Yes No1. Pay the proceeds to (Select one and complete the corresponding section below):

Owner at address of record via mail. (Default) Skip to section E – Withholding Election & Tax Reporting. Owner via Electronic Funds Transfer (EFT)/Direct Deposit. Complete question 2 then skip to section E – Withholding Election &

Tax Reporting. Receiving company via direct rollover, trustee-to-trustee transfer or exchange. SWP is not available for tax-free direct rollovers, trustee-

to-trustee transfers, or 1035 exchanges. Specify company name below and attach signed letter of acceptance from receiving company. For additional information, refer to section H – Disclosures.

Receiving company name: Allowable alternate payee and/or alternate address (Not available for Qualified Employee Benefit Plan Owned, Corporate Owned

Non-Qualified contracts, or Non-Qualified Deferred Compensation Plan contracts.) Complete question 3 then continue to section E – Withholding Election & Tax Reporting. A Notary stamp/seal is required in section F – Agreements & Signatures. Refer to section H – Disclosures for allowable alternate payees.

Owner via Electronic Funds Transfer (EFT)/Direct Deposit (Wire transfers are not available.)

Deposit slips and starter checks will not be accepted. Refer to section H – Disclosures for further information. If this section is not completed or insufficient documentation is provided, a check will be mailed to the Owner at the address of record.The name displayed on the voided check or signed specification (spec) sheet/letter of instruction from the financial institution must match the Owner/Participant in order to electronically transfer the payment to the account. Once the form has been received in good order, the distribution may take 3-5 business days to post to your bank account.

2. Bank account type (Select one): Savings (Submit a signed specification (spec) sheet/letter of instruction from the financial institution) Checking (Attach a voided check or submit a signed specification (spec) sheet/letter of instruction from the financial institution)

Allowable Alternate Payee and/or Alternate Address (Distributions may not be sent to an Agent/Broker address.)

Refer to section H – Disclosures for allowable alternate payees.3. Allowable alternate payee information:

a. Payee name: b. Mailing address (PO Box or Street, Apt. or Suite #, City & State or Country, ZIP/Postal Code):

c. Charitable Organization Taxpayer Identification Number (SSN/ITIN/EIN):


E Withholding Election & Tax Reporting Information � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �Do not complete for corporate owned non-qualified contracts, non-qualified deferred compensation plan contracts, or Qualified Employee Benefit Plan contracts, other than Governmental 457(b) Plan distributions being paid directly to the Plan Participant. For Governmental 457(b) Plan distributions being paid directly to the Plan Participant / Annuitant, this section must be completed by the Plan Participant / Annuitant.

Payments you receive from Massachusetts Mutual Life Insurance Company (“MassMutual”) are subject to federal income tax withholding unless you elect not to have withholding apply. Withholding will only apply to the portion of your payment that is already included in your income subject to federal income tax. There will be no withholding on the return of your own nondeductible contributions to the contract. If we do not know what portion of a distribution is taxable, we will withhold on the net amount after charges.

Once a payment has been made, the withholding election applicable to that payment cannot be changed. If you are establishing automatic pay-ments, any withholding election you make will remain in effect until you revoke it by returning to us a signed and dated revocation of election. If you elect not to have withholding apply to your other payments, or if you do not have enough federal income tax withheld from these payments, you may be responsible for the payment of estimated tax and/or be subject to estimated tax penalties. A distribution taken before age 59½ may be subject to a 10% penalty. Not withstanding any election below, eligible rollover distributions from a Governmental 457(b) Deferred Compensation Plan are subject to a mandatory 20% withholding. Refer to “Special Notice Regarding Rollover Options” in section H – Disclosures for more information about eligible rollover distributions.

State income tax withholding may also apply. State income tax withholding requirements vary by state. If required under the laws of the state in which you live, state income tax withholding will also apply. For more information on the withholding requirements in your state, see State Income Tax Withholding Disclosure.

You should consult with a professional tax advisor before you begin receiving payments or before changing your election. Review the tax withholding disclosures in section H.

1. Federal Tax Withholding ElectionCheck the appropriate box below to make your withholding election for payments other than eligible rollover distributions subject to 20% withholding. If no withholding election is affirmatively made, a 10% federal tax will be withheld, subject to certain exceptions.

Do not withhold Withhold 10% (Default) Withhold more than 10% (Specify): %

2. State Tax Withholding Elections*Check the appropriate box to make a state income tax withholding election. If no election is affirmatively made, we will apply the default withholding rules in your state, if any.

For residents of states other than Georgia, Minnesota & South Carolina:

Do not withhold state unless mandatory

Apply state default withholding

Withhold the following (Specify)**:

% or $

**must comply with any state minimum

For residents of Georgia, Minnesota or South Carolina:

Do not withhold state unless mandatory Use the default assumption of Single with Zero Allowances Use the following filing status and allowances:

a. Marital status (Select one):

Single Married Head of Householdb. Number of allowances: c. Withhold additional state amount (If applicable):

$

* Certain states require a state specific form in order to elect other than the default state withholding. See attached State Income Tax Withholding Disclosure - FR2070.

3. For Roth IRA OnlyIf Roth IRA, provide year of initial contribution to this or a previous Roth IRA contract ________________. If blank, the contribution year the MassMutual Roth IRA contract was established will be used for tax reporting purposes.

4. Disability Distribution (If applicable):

Check box if you can claim this as a disability distribution. Other requirements needed. Refer to Distribution Eligibility in section H – Disclosures for allowable alternate payees.


F Agreements & Signatures � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �Withdrawals may be subject to a contingent deferred sales charge/surrender charge. Withdrawals from Equity Edge, CM Windows, Panorama Plus Fixed Account, MassMutual Transitions/Transitions Select Long-Term Guarantee Fixed Accounts, and LifeTrust Fixed Account may also be subject to a market value/interest rate factor adjustment. Withdrawals from Stable Voyage contracts that occur during a 3, 4, 5, 7, or 9 year guarantee period are subject to surrender charges unless they occur during the 30 day window period at the end of the guarantee period.

By completing question D2 – Electronic Funds Transfer (EFT)/Direct Deposit, I, the Owner, authorize MassMutual to deposit, via Electronic Funds Transfer, all payments to the bank account identified in section D. Payments made via EFT will fully satisfy MassMutual’s obligation to make payments to me. Should MassMutual make an overpayment to me, I also authorize MassMutual to debit the bank account identified in section D in the amount of the overpayment in order to recoup the amount overpaid to me. To cancel this agreement, I must notify the MassMutual Service Center.

By signing below, I, the Owner, waive my right to receive a reasonable time (at least 30 days notice) to consider my rollover distribution options and I acknowledge that I have read all disclosures.

Taxpayer Certification. By my signature, I, the Owner, certify under penalties of perjury that: (1) the number shown in section A (or below for a Governmental 457(b) Plan Participant/Annuitant) is my correct Taxpayer Identification Number; (2) I am not subject to backup withholding; (3) I am a U.S. person (including U.S. resident alien); and (4) the FATCA code entered on this form (if any) indicating that I am exempt from FATCA reporting is correct. Strike out any of these statements if incorrect. Note: While we are required by the IRS to include item 4 above, FATCA does not apply to a U.S. account owned by a U.S. person, so we have not included the ability to enter an exemption code. If you have indicated that you are not a U.S. person, any applicable FATCA information will be captured on the Form W-8.

The Internal Revenue Service (IRS) does not require your consent to any provision of this document other than the certifications required to avoid backup withholding.

Annuitant’s Social Security Number (Complete for Governmental 457(b) Deferred Compensation):

As Owner/Trustee/Administrator, I certify that the information shown on this form is correct and complete and that I accept liability for the accuracy of the information on this form.

Signature of Owner:

Printed name: Date:

Title (If applicable):

Signature of Joint Owner (If applicable):

Printed name: Date:

Signature of Annuitant (Required for 457(b) Plans):

Printed name: Date:

Signature of Irrevocable Beneficiary (If applicable):

Printed name: Date:


F Agreements & Signatures continued • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •Owner Notary Stamp/Seal

A Notary stamp/seal is required for the Owner when: (1) proceeds are paid or sent to an allowable alternate payee (Refer to section H – Disclosures); (2) proceeds are sent to an address other than the address of record; or (3) proceeds are sent to an address that has been changed in the past 30 days. Notary services are offered at most banks and credit unions. A Notary stamp is not required if made payable to a financial institution that has provided a letter of acceptance. On , (mm/dd/yyyy) (full legal name)

personally appeared before me and is known to me and/or satisfactorily proved to me to be the person who signed this document of his/her own free will and accord.

Signature of Notary Public:

State/County where signed:

My commission expires (mm/dd/yyyy):

Affix Notary Stamp/Seal

Joint Owner Notary Stamp/Seal

A Notary stamp/seal is required for the Joint Owner when: (1) proceeds are paid or sent to an allowable alternate payee (Refer to section H – Disclosures); (2) proceeds are sent to an address other than the address of record; or (3) proceeds are sent to an address that has been changed in the past 30 days. Notary services are offered at most banks and credit unions. A Notary stamp is not required if made payable to a financial institution that has provided a letter of acceptance. On , (mm/dd/yyyy) (full legal name)

personally appeared before me and is known to me and/or satisfactorily proved to me to be the person who signed this document of his/her own free will and accord.

Signature of Notary Public:

State/County where signed:

My commission expires (mm/dd/yyyy):

Affix Notary Stamp/Seal

G Submission & Contact Information � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �For more information or general questions, use the resources below. Once you have reviewed and completed this form, return pages 1 - 7 for processing. We will only accept responsibility for forms that are returned as indicated below.

Service Center:(800) 272-2216

Fax:(866) 329-4272

Mail: MassMutualPO Box 9067 Springfield, MA 01102-9067

Overnight Mail: MassMutual 1295 State Street Springfield, MA 01111-0001

Email: [email protected]



H Disclosures � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �If you have elected an optional guaranteed minimum accumula-tion benefit, guaranteed minimum income benefit or a guaranteed minimum withdrawal benefit with your variable annuity contract and would like to understand the impact of a withdrawal on the benefit provided by those features, contact us to obtain a person-alized calculation demonstrating the effect of a withdrawal.Minimum Withdrawal Amounts & Contract BalancesFixed Products not mentioned, contact the Service Center at 1-800-272-2216.For MassMutual Transition contracts. You may not participate in the Systematic Withdrawal Program if you elected the Nursing Home Waiver Benefit and we are currently waiving the contingent deferred sales charge in accordance with that benefit.Nursing Home Waiver. Referred to as Nursing Home Benefit Waiver or Nursing Home Waiver of Contingent Deferred Sales Charge Rider for MassMutual Evolution, MassMutual Transitions Select, and Mass-Mutual Transitions products. Referred to as Nursing Home and Hospi-tal Waiver for Odyssey Select and Stable Voyage contracts.Distribution Eligibility (Only applicable to distributions from a Governmental 457(b) Deferred Compensation Plan that are being paid to the Participant or Beneficiary.) In order for a distribution to be paid directly to a participant under a governmental 457(b) plan, the participant’s eligibility to receive a distribution must be indicated. Distributions can be made to the participant under the following circumstances:• Attainment of age 70 ½• Termination of plan• Severance from employment• Compliance with a Qualified Domestic Relations Order (QDRO)• Qualified birth or adoption distributions, as defined in IRC section

72(t)(2)(H) One-time Partial WithdrawalWithdrawal Method Gross vs. NetGross of any applicable contingent deferred sales charges (CDSC) and/or tax withholding. The requested amount will be with-drawn from the contract and any applicable CDSC and tax withholding will be deducted from the requested amount. You will receive a pay-ment in the amount of the remainder.Net of any applicable contingent deferred sales charges (CDSC) and/or tax withholding. You will receive a payment for the amount re-quested. The amount withdrawn from your contract will be increased to the extent needed to result in payment to you of the requested amount, after the deduction of any applicable CDSC and/or tax withholding. If there are not sufficient funds to provide the requested amount net of all charges, the request will be processed as a gross amount.

Excess contribution. If the excess contribution will be removed by the due date of your return (including extensions), we will automati-cally adjust the amount of your distribution for any gain or loss attrib-utable to the excess amount. If your distribution includes an amount representing gain, it will generally be taxable to you in the year that the excess contribution was made. If the excess contribution is removed after the due date of your return, we will make no adjustment for gain or loss. We assume that any excess contribution removed on or be-fore October 15th of the year after the tax year listed in section B1 has been removed prior to the due date of your return. If our assumption is incorrect, you must let us know prior to processing your distribution. Consult your tax advisor or IRS Publication 590 for more information about correcting excess IRA contributions. MassMutual Equity EdgeBenefit Period Elected• Withdrawals outside of a window period. While you are participating

in a benefit period, if you make a withdrawal outside of the win-dow period, your withdrawal will be subject to a contingent deferred sales charge (only during the initial benefit period) and any applica-ble market value adjustment. Your Principal Protection Benefit will also be adjusted.

• Withdrawals during the window period. While you are participating in a benefit period, if you make a withdrawal during the window period, your withdrawal will not be subject to a contingent deferred sales charge or any applicable market value adjustment. Your Prin-cipal Protection Benefit will be adjusted unless your withdrawal is effective on the benefit period expiration date.

• Unless you request otherwise, your withdrawal request will be ef-fective on your benefit period expiration date.

No Benefit Period Elected• If you make a withdrawal while your entire contract value is invested

in the MML Money Market sub-account, your withdrawal will not be subject to a contingent deferred sales charge (CDSC) or any appli-cable market value adjustment. Your withdrawal will be effective on the business day we receive this fully completed form.

Principal Protection Benefit Adjustments• Your principal protection benefit will be reduced by the same ratio

of any partial withdrawal you make prior to the end of your benefit period. For example, assume $100,000 is the principal amount that is protected. Your current contract value is $120,000 and you with-draw 10% ($12,000), leaving a contract value of $108,000. Your $100,000 principal protection benefit is reduced by the same ratio, 10% ($10,000) to $90,000. If you make a full withdrawal on any day prior to the end of your benefit period, the principal protection ben-efit will not be applied to your contract. You will receive an amount equal to your contract value less a contingent deferred sales charge and/or market value adjustment. This amount may be more or less than your original purchase payment.


H Disclosures continued • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •Systematic Withdrawal ProgramSWP is not available on a 457(b) contract paid to the participant due to unforeseen emergency or as a qualified birth or adoption distribution.Substantially Equal Periodic Payments. A partial withdrawal from a contract that has a substantially equal periodic payment stream running may be considered an impermissible modification and may subject all of your prior payments to the 10% penalty, plus interest. Consult your tax advisor before proceeding. Note: If you are taking your distribution as part of a series of substantially equal periodic payments under section 72(t) or 72(q) described in section C, your withdrawal will be made net of any applicable contingent deferred sales charges/surrender charges and gross of any tax. Under the RMD Method (Life Expectancy): MassMutual will recalculate payments on December 31 of each year, using the closing account balance on that date and the Uniform Lifetime Table. If your payments were calculated under this method using a different table, you must recalculate the payments each year on your own. Changing the life expectancy table used to calculate payments is only allowed in very limited circumstances.If the series of payments is subsequently modified (other than by reason of death or disability) before the taxpayer attains age 59½, or prior to the close of the five-year period beginning with the date of the first payment and after the taxpayer attains age 59½, the 10% premature distribution penalty tax will be imposed retroactively on prior distributions, plus interest. The period described must be completed before additional distributions can be received to avoid imposition of the 10% premature distribution penalty. The IRS has indicated that a series of payments will be considered modified if, after the date on which the account was valued to determine your payments, there is.• A withdrawal in addition to your schedule payments;• Any addition to the account balance other than gains or losses;• Any nontaxable transfer of a portion of the account balance to an-

other retirement Plan; or• A rollover of the amount received resulting in such amount not

being taxable.• Other transactions, in addition to those listed above, may also be

considered as modifying a series of payments.Benefit Period Expiration Date• Your withdrawal may be subject to a CDSC and will result in an

adjustment to your principal protection benefit if the withdrawal is not effective on the benefit expiration date.

Interest Only Systematic Withdrawal ProgramWithdrawals may be subject to a surrender charge. If chosen after issue, withdrawals will begin one modal frequency as specified, from the election date. Note: you will receive interest earned in the frequency indicated from the date your request is processed, which may not account for all interest in your contract. MassMutual Odyssey: The contract value must be at least $15,000 to participate. If the interest earned during a frequency is less than $25, the systematic withdrawal for that frequency will not process. Your systematic withdrawals will continue when the interest earned during a frequency is greater than $25. MassMutual Odyssey Plus, MassMutual Odyssey Select, and MassMutual Stable Voyage: Currently, there is no contract minimum to participate. If the interest earned during a frequency is less than $100, the Company reserves the right to change the frequency. The in-terest only free withdrawal amount applies to all interest earned during

the immediately preceding calendar year up to a maximum credited rate of 10% for each purchase payment. No surrender charges will apply. Interest is compounded on a daily basis; therefore your payment will vary depending on the number of days in each month. Funds will be withdrawn on a first in, first out basis, in accordance with your con-tract. Note: the interest will be withdrawn one frequency prior to the start date. Below is a hypothetical example of how the Interest Only Systematic Withdrawal Program works.Hypothetical Example*Based on the following hypothetical values: Contract Issue Date: 01/02/2004; Interest Rate: 5%; Deposit Amount: $100,000.00

Date# of Days In Period

Amt of Interest Only SWP

Check

Acct Value after Interest Only SWP

check02/02/2010 31 $415.18 $100,000.0003/02/2010 29 $374.94 $100,000.0004/02/2010 31 $415.18 $100,000.00

* These numbers are hypothetical only and are not meant to imply the performance of any MassMutual Odyssey, MassMutual Odyssey Plus, MassMutual Odyssey Select, or MassMutual Stable Voyage contract.Distribution InstructionsDistributions may be paid in cash, rolled or transferred to a direct roll-over or transfer vehicle. If all or a portion of the distribution is to be paid to a party other than the Owner, they must meet MassMutual’s definition of an allowable alternate payee. Allowable Alternate Payees. If all or a portion of the distribution is to be paid to a party other than the Owner, they must meet MassMutual’s definition of an allowable alternate payee.Allowable alternate payees:• Annuitant (Available for Governmental 457(b) Plans only)• Brokerage accounts for the benefit of the Owner (i.e. brokerage

account in the Owner’s name)• Non-rollover/transfer/exchanges to another MassMutual contract

or policy in the Owner’s name• Charitable organization (Available only for IRAs where the Owner

is 70½ years of age or older. Taxpayer Identification Number of charity must also be provided at time of request.)

If the definition of an allowable alternate payee is met, fill in the appropriate name in section D. For Rollovers/1035 Exchange. If all or a portion of the distribution is to be a direct rollover or trustee to trustee transfer, fill in the name of the receiving institution in section D. A signed letter of acceptance from the receiving company must be included for a direct rollover or trustee to trustee transfer.For direct rollovers, transfers or 1035 exchanges a signed letter of acceptance from the receiving company must be included. The letter of acceptance must be on company letterhead and include:• MassMutual contract/certificate number or the Owner’s name

and SSN,• Acceptance wording or wording that specifically states

MassMutual is to mail the check to the receiving company,• Market type of the contract the funds are moving to,• Mailing instructions, • An authorized signature


H Disclosures continued • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •Indirect IRA Rollovers. Federal tax law also allows you to contribute an IRA distribution to another IRA or qualified plan through an indirect rollover, by depositing the distribution into an IRA or eligible plan within 60 days after you receive it. However, you are limited to one such indirect rollover from any IRA you own (including traditional IRAs, SEP IRAs, SIMPLE IRAs and Roth IRAs) to another IRA within any 12 month period. This limitation does not, however, apply to a rollover that constitutes a conversion from an IRA to a Roth IRA. This limitation also does not apply to direct rollovers. If you intend to rollover a distribution from one IRA to another IRA, you should consider doing so as a direct rollover.Withholding Election and Tax Reporting Information IRA and Non-Qualified Plan contracts. If this withdrawal is not a direct rollover, trustee to trustee transfer, or 1035 example the taxable portion of the withdrawal will be subject to 10% income tax withholding, unless you elect not to have withholding apply. You may revoke your withholding election at any time. Your election will remain in effect until revoked. You may incur penalties under the estimated tax rules if your withholding and estimated tax payments are not sufficient. Contact your tax advisor or local IRS office with any questions regarding withholding and estimated tax rules.Qualified distributions from a Roth IRA are tax-free and are, therefore, not subject to withholding.Governmental 457(b) Plan distributions paid to a participant. If you choose to have a distribution from a Governmental 457(b) Plan paid to you, then you will receive only 80% of the payment because your Plan is required to withhold 20% of the distribution and send it to the IRS as income tax withholding to be credited against your taxes. Your distribution will be taxed in the current year unless you roll it over.If a portion of your distribution is not an eligible rollover distribution or Plan to Plan transfer, withholding is required at 10% of the amount redeemed, unless you elect not to have withholding apply. If you elect to have no tax withheld, you may be responsible for the payment of estimated tax. You may incur penalties under the estimated tax rules if your withholding and estimated tax payments are not sufficient. If you have any questions about this, contact your tax advisor or local IRS office.Distributions rolled over (converted) to a Roth IRA will be tax reported in the year the conversion was made.Plan administrators of Governmental 457(b) Deferred Compensation Plans, rather than the payor, are generally liable for withholding upon distributions. A Plan administrator is not liable for withholding if the ad-ministrator directs the payor in writing to withhold the tax and provides the payor with any required information.You can roll over the distribution by paying it to your Traditional IRA, SEP IRA, Tax Sheltered Annuity, Qualified Employer Plan or a transfer to another Governmental 457(b) Plan that accepts your rollover within 60 days after you receive your distribution. The amount rolled over will not be taxed until you take it out of the new or existing contract. If you want to roll over 100% of the distribution to a new or existing contract, you must find other money to replace the 20% that was withheld. If you roll over only the 80% that you received, you will be taxed on the 20% that was withheld and that is not rolled over.Premature Distribution Penalty. Section 72(t) of the Code impos-es a 10% penalty tax on the taxable portion of any distribution from qualified retirement Plans, including contracts issued and qualified

under Code Sections 401 (Pension and Profit-Sharing Plans), 408 (In-dividual Retirement Annuities-IRAs), 403 (Tax Sheltered Annuity), and 408A (Roth IRAs). The penalty tax does not apply to distributions from a 457(b) Deferred Compensation Plan. However, amounts that are rolled over to a 457(b) Deferred Compensation Plan are required to be tracked separately in order for them to continue to be subject to the premature distributions penalty under IRC Section 72(t). Exceptions from the penalty tax are as follows:• Distributions made on or after you reach age 59½,• Distributions made after your death or disability (as defined in

Code Section 72(m)(7)),• After separation from service, distributions that are part of a

series of substantially equal periodic payments made not less frequently than annually for your life (or life expectancy) or the joint lives (or joint life expectancies) of you and your designated beneficiary (in applying this exception to distributions from IRAs, a separation from service is not required),

• Distributions made after separation from service if you have reached age 55 (not applicable to distributions from IRAs),

• Distributions of certain automatic enrollment contributions re-quested to be withdrawn within 90 days of the first contribution,

• Distributions of up to $5,000 made to you from a defined contri-bution plan or IRA if the payment is a qualified birth or adoption distribution,

• Certain distributions made while you are on active duty if you were a member of a reserve component called to duty after Sep-tember 11, 2001 for more than 179 days,

• Distributions excepted from the additional income tax by federal legislation relating to certain emergencies and disasters,

• Distributions made to you up to the amount allowable as a deduc-tion to you under Code Section 213 for amounts you paid during the taxable year for medical care (without regard to whether you itemize deductions for the taxable year),

• Distributions made directly to the government to satisfy a federal tax levy made on a qualified retirement Plan or IRA,

• Distributions made to an alternate payee pursuant to a qualified domestic relations order (not applicable to distributions from IRAs),

• Distributions from an IRA for the purchase of medical insurance (as described in Code Section 213(d)(1)(D)) for you and your spouse and dependents if you received unemployment compen-sation for at least 12 weeks and have not been re-employed for at least 60 days,

• Distributions from an IRA to the extent they do not exceed your qualified higher education expenses (as defined in Code Section 72(t)(7)) for the taxable year, and

• Distributions from an IRA, which are, qualified first-time home-buyer distributions (as defined in Code Section 72(t)(8)).

MassMutual does not track for all of the above exceptions and you may have to file for these exceptions on your own.


H Disclosures continued • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •Section 72(q) of the Code imposes a similar 10% penalty tax on the taxable portion of any distribution from a non-qualified annuity. Excep-tions from the penalty tax are as follows:• Distributions made on or after you reach age 59½,• Distributions made after your death or disability (as defined in

Code Section 72(m)(7)),• Distributions that are part of a series of substantially equal period-

ic payments made not less frequently than annually for your life (or life expectancy) or the joint lives (or joint life expectancies) of you and your designated beneficiary.

Aggregation. Internal Revenue Code Section 72(e)(11) states that multiple non-qualified annuity contracts that are issued within the same calendar year to the same Owner/and or co-Owner by the same company or its affiliates, must be aggregated and treated as one an-nuity contract for purposes of determining the tax consequences of any distribution. Such treatment may result in more rapid taxation on distributed amounts than if the contracts were treated separately.Disability Distribution. An individual shall be considered to be dis-abled if he is unable to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or to be of long-continued and indefinite duration. An individual shall not be considered to be disabled unless he furnished proof of the existence thereof in such form and manner as the Internal Revenue Service may require. To enable a distribution to be coded on Form 1099-R as being exempt from the premature distribution penalty on account of disability, MassMutual requires the Owner/Participant to provide documentation of proof of disability with the withdrawal request. If valid documentation is not re-ceived with the withdrawal request, the distribution will be coded on Form 1099-R as a premature or normal distribution as appropriate. Acceptable forms of documentation include a written physician’s state-ment certifying that the contract Owner is disabled within the scope of IRC Section 72(m)(7) (valid for one year from date of letter) or a copy of the Social Security Administration documentation stating that the individual is disabled.30 Day Notice. The Internal Revenue Code gives you a reasonable time (at least 30 days) to consider making a direct rollover of your eligible retirement Plan benefits to an eligible Qualified Employer Plan, a Traditional IRA, SEP IRA, Tax Sheltered Annuity, or Governmental 457(b) Plan rather than receiving an eligible rollover distribution subject to mandatory withholding. You may waive this right by signing section F of the form without modification. Replacement Information If you are considering replacing this contract, the proposed replace-ment may not be in your best interest. The release of values from this contract may affect the guaranteed and non-guaranteed elements and surrender values. Certain fees and/or tax consequences may also be associated with this request. To help determine whether replacing the contract is in your best interest, a contract summary is available upon request. Contact our Service Center at (800) 272-2216, Mon-day through Friday between 8:00 a.m. and 8:00 p.m. Eastern time. By signing and submitting this form, you acknowledge that you are waiving the right to receive a contract summary and wish to proceed without receiving one.The release of values from this contract may affect the guaranteed and non-guaranteed elements and surrender values. Certain fees and/or tax consequences may also be associated with this request.

Additional Signature and Certification Information for Non-Qual-ified contracts. The Company has no liability or responsibility for the tax treatment of any surrender proceeds paid to another insurance company, whether intended to qualify as a 1035 exchange or for any other purpose. Not all exchanges qualify for tax-deferral under Section 1035 of the Internal Revenue Code. You should consult your own tax advisor.Additional Signature and Certification Information for Govern-mental 457(b) Deferred Compensation Plan contracts. This section must be signed and dated by the Trustee/Plan Administrator/Employ-er, as certification that all information provided is true and accurate. Your signature as Participant indicates that you agree to the Terms and Conditions for 457(b) Plan distributions as provided in this sum-mary. If you elect not to waive your right to receive a reasonable time to consider your rollover/distribution options, cross out that sentence and initial the margin. Special Notice Regarding Rollover Options (Applicable to distri-butions from a Governmental 457(b) plan paid to a participant or beneficiary only.)Rollover Options. This following information is provided because all or a portion of a payment that you are receiving from a Plan is eligible to be rolled over to an IRA or employer plan. This notice is intended to help you decide whether to do such a rollover. This notice describes the rollover rules that apply to payments from the Plan that are not from a designated Roth account (a type of account with special tax rules in some employer plans). Rules that apply to most payments from a plan are described in the “General Information About Rollovers” section. Special rules that only apply in certain circumstances are described in the “Special Rules and Options” section. General Information About RolloversHow can a rollover affect my taxes? You will be taxed on a payment from MassMutual if you do not roll it over. If you are under age 59½ and do not do a rollover, you will also have to pay a 10% additional income tax on early distributions (unless an exception applies). However, if you do a rollover, you will not have to pay tax until you receive payments later and the 10% additional income tax will not apply if those payments are made after you are age 59½ (or if an exception to the 10% additional income tax applies).What types of retirement accounts and plans may accept my rollover? You may roll over the payment to either a Traditional IRA (an Individual Retirement Account or Individual Retirement Annuity) or an employer plan (a Tax-Qualified Plan, Section 403(b) Plan, or Governmental Section 457(b) Plan) that will accept the rollover. The rules of the IRA or employer Plan that holds the rollover will determine your investment options, fees, and rights to payment from the IRA or employer Plan. (For example, IRAs are not subject to spousal consent rules, and IRAs may not provide loans). Further, the amount rolled over will become subject to the tax rules that apply to the IRA or employer Plan.How do I do a rollover? There are two ways to do a rollover. You can do either a direct rollover or a 60-day rollover.If you do a direct rollover, MassMutual will make the payment directly to your IRA or an employer Plan. You should contact the IRA sponsor or the Administrator of the employer Plan for information on how to do a direct rollover.


H Disclosures continued • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •If you do not do a direct rollover, you may still do a rollover by making a deposit into an IRA or eligible employer Plan that will accept it. Generally, you will have 60 days after you receive the payment to make the deposit. If you do not do a direct rollover, MassMutual is required to withhold 20% of the payment for federal income taxes (up to the amount of cash and property received other than employer stock). This means that, in order to roll over the entire payment in a 60-day rollover, you must use other funds to make up for the 20% withheld. If you do not roll over the entire amount of the payment, the portion not rolled over will be taxed and will be subject to the 10% additional income tax on early distributions if you are under age 59½ (unless an exception applies). How much may I roll over? If you wish to do a rollover, you may roll over all or part of the amount eligible for rollover. Any payment from the Plan is eligible for rollover, except:• Certain payments spread over a period of at least 10 years or

over your life or life expectancy (or the joint lives or joint life expectancy of you and your beneficiary);

• Required minimum distributions after age 70 ½ (if you were born before July 1, 1949), after age 72 (if you were born after June 30, 1949), or after death;

• Distributions on account of unforeseeable emergency;• Corrective distributions of contributions that exceed tax law

limitations;• Cost of life insurance paid by the plan;• Payments of certain automatic enrollment contributions that you

request to withdraw within 90 days of your first contribution;• Distributions of certain premiums for health and accident

insurance.If I don’t do a rollover, will I have to pay the 10% additional income tax on early distributions? Distributions from a Governmental section 457(b) plan are not subject to the 10% additional income tax on early distributions.If I do a rollover to an IRA, will the 10% additional income tax apply to early distributions from the IRA? If you receive a payment from an IRA when you are under age 59½, you will have to pay the 10% additional income tax on early distributions from the IRA, unless an exception applies. See list of exceptions to the 10% additional income tax in the Withholding and Tax Reporting Information section of this section H.Will I owe state income taxes? This information does not describe any state or local income tax rules (including withholding rules). Special Rules and OptionsIf you miss the 60-day rollover deadline. Generally, the 60-day rollover deadline cannot be extended. However, the IRS has the limited authority to waive the deadline under certain extraordinary circumstances, such as when external events prevented you from completing the rollover by the 60-day rollover deadline. Under certain circumstances, you may claim eligibility for a waiver of the 60-day rollover deadline by making a written self-certification. Otherwise, to apply for a waiver, you must file a private letter ruling request with the IRS. Private letter ruling requests require the payment of a nonrefundable user fee. For more information, see IRS Publication 590-A, Contributions to Individual Retirement Arrangements (IRAs).

If you are an eligible retired public safety officer and your pension payment is used to pay for health coverage or qualified long-term care insurance. If the Plan is a governmental Plan, you retired as a public safety officer, and your retirement was by reason of disability or was after normal retirement age, you can exclude from your taxable income Plan payments paid directly as premiums to an accident or health Plan (or a qualified long-term care insurance contract) that your employer maintains for you, your spouse, or your dependents, up to a maximum of $3,000 annually. For this purpose, a public safety officer is a law enforcement officer, firefighter, chaplain, or member of a res- cue squad or ambulance crew.If you roll your payment to a Roth IRA. If you roll over a payment from the Plan to a Roth IRA, a special rule applies under which the amount of the payment rolled over (reduced by any after-tax amounts) will be taxed. In general, the 10% additional income tax on early distributions will not apply. However, if you take the amount rolled over out of the Roth IRA within the 5-year period that begins on January 1 of the year of the rollover, the 10% additional income tax will apply (unless an exception applies). If you roll over the payment to a Roth IRA, later payments from the Roth IRA that are qualified distributions will not be taxed (including earnings after the rollover). A qualified distribution from a Roth IRA is a payment made after you are age 59½ (or after your death or disability, or as a qualified first- time homebuyer distribution of up to $10,000) and after you have had a Roth IRA for at least 5 years. In applying this 5-year rule, you count from January 1 of the year for which your first contribution was made to a Roth IRA. Payments from the Roth IRA that are not qualified distributions will be taxed to the extent of earnings after the rollover, including the 10% additional income tax on early distributions (unless an exception applies). You do not have to take required minimum distributions from a Roth IRA during your lifetime. For more information, see IRS Publication 590, Individual Retirement Arrangements (IRAs).


H Disclosures continued • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •If you are not the Plan ParticipantPayments after the death of the Participant. If you receive a distribution after the Participant’s death that you do not roll over, the distribution will generally be taxed in the same manner described elsewhere in this notice. However, the 10% additional tax on early distributions and the special rules for public safety officers do not apply.If you are a surviving spouse. If you receive a payment from the Plan as the surviving spouse of a deceased Participant, you have the same rollover options that the Participant would have had, as described elsewhere in this notice. In addition, if you choose to do a rollover to an IRA, you may treat the IRA as your own or as an inherited IRA.An IRA you treat as your own is treated like any other IRA of yours, so that payments made to you before you are age 59½ will be subject to the 10% additional income tax on early distributions (unless an exception applies) and required minimum distributions from your IRA do not have to start until after you are age 70½ (if you were born before July 1, 1949) or age 72 (if you were born after June 30, 1949).If you treat the IRA as an inherited IRA, payments from the IRA will not be subject to the 10% additional income tax on early distributions. However, if the Participant had started taking required minimum distributions, you will have to receive required minimum distributions from the inherited IRA. If the Participant had not started taking required minimum distributions from the Plan, you will not have to start receiving required minimum distributions from the inherited IRA until the year the Participant would have been age 70½ (if the participant was born before July 1, 1949) or age 72 (if the participant was born after June 30, 1949).If you are a surviving beneficiary other than a spouse. If you receive a payment from the Plan because of the Participant’s death and you are a designated beneficiary other than a surviving spouse, the only rollover option you have is to do a direct rollover to an inherited IRA. Payments from the inherited IRA will not be subject to the 10% additional income tax on early distributions. You will have to receive required minimum distributions from the inherited IRA. Payments under a qualified domestic relations order. If you are the spouse or former spouse of the Participant who receives a payment from the Plan under a qualified domestic relations order (QDRO), you generally have the same options the Participant would have. For example, you may roll over the payment to your own IRA or an eligible employer plan that will accept it. However, payments under the QDRO will not be subject to the 10% additional income tax on early distributions.

If you are a nonresident alien. If you are a nonresident alien and you do not do a direct rollover to a U.S. IRA or U.S. employer Plan, instead of withholding 20%, MassMutual is generally required to withhold 30% of the payment for federal income taxes. If the amount withheld exceeds the amount of tax you owe (as may happen if you do a 60-day rollover), you may request an income tax refund by filing Form 1040NR and attaching your Form 1042-S. See Form W-8BEN for claiming that you are entitled to a reduced rate of withholding under an income tax treaty. For more information, see also IRS Publication 519, U.S. Tax Guide for Aliens, and IRS Publication 515, Withholding of Tax on Nonresident Aliens and Foreign Entities.Other special rules. You may have special rollover rights if you recently served in the U.S. Armed Forces. For more information on special rollover rights related to U.S. Armed Forces, see IRS Publication 3, Armed Forces’ Tax Guide. You may also have special rollover rights if you were affected by a federally declared disaster (or similar event), or if you received a distribution on account of a disaster. For more information on special rollover rights, see the IRS website at www.irs.gov.For More InformationYou may wish to consult with the Plan administrator or payor, or a professional tax advisor, before taking a payment from the Plan. Also, you can find more detailed information on the federal tax treatment of payments from employer plans in: IRS Publication 575, Pension and Annuity Income; IRS Publication 590-A, Contributions to Individual Retirement Arrangements (IRAs); and IRS Publication 590-B, Distributions from Individual Retirement Arrangements (IRAs). These publications are available from a local IRS office, on the web at www.irs.gov, or by calling 1-800-TAX-FORM.

of 2 State Income Tax Withholding Disclosure FR2070-US 0720

State Income Tax Withholding Disclosure

State income tax withholding requirements on taxable distributions vary by state. State income tax, if required by your state of residence, will be withheld by MassMutual as detailed below. If you have questions regarding the withholding rules that we will apply in your state, or if you want to make a state income tax withholding request, contact the MassMutual Service Center at 1-800-272-2216 (Monday through Friday, 8am-8pm Eastern Time).

State Withholding Requirements � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �If you are a resident of... State income tax will....

Alabama, Colorado, Hawaii, Idaho, Indiana, Kentucky, Louisiana, Minnesota, Mississippi, Missouri, Montana, New Jersey, New Mexico, New York*, North Dakota, Ohio, Pennsylvania, Rhode Island, South Carolina, Utah, West Virginia or Wisconsin

Not be withheld unless you request state income tax withholding.

Alaska, Florida, Nevada, New Hampshire, South Dakota, Tennessee, Texas, Washington or Wyoming Not be withheld.

Arizona or IllinoisBe withheld from periodic payments (i.e. annuitized payments) only if you request state income tax withholding. State income tax will not be withheld from any other distribution.

Arkansas, California, Iowa, Maine, North Carolina, Oklahoma or Oregon

Be withheld if federal income tax is withheld, unless you opt out of state income tax withholding. However, even if federal income tax is not withheld, you may request that state income tax be withheld. In Arkansas and North Carolina, you may not opt-out of eligible rollover distributions. In Maine you may not opt-out of non-periodic payments.

Connecticut Be withheld, unless you claim exemption on form CT-W4P.

Delaware, Kansas, Massachusetts, Nebraska or Vermont Be withheld if federal income tax is withheld. However, even if federal in-come tax is not withheld, you may request that state income tax be withheld.

District of ColumbiaBe withheld only on a full surrender of a qualified contract. State income taxes will not be withheld from any other distribution, unless you request state income tax withholding.

GeorgiaBe withheld from periodic payments (i.e. annuitized payments), unless you opt-out of withholding. State income taxes will not be withheld from any other distributions, unless you request state income tax withholding.

MarylandBe withheld from eligible rollover distributions, if federal income tax is with-held. You may request withholding on distributions from qualified contracts and non-qualified Annuities.

Michigan Be withheld, unless you opt out of withholding by submitting form MI W-4P.

Virginia

Be withheld if federal income tax is withheld, unless your contract is an IRA or SEP-IRA. If your contract is held as an IRA or SEP-IRA, state income taxes will not be withheld unless you request state income tax withholding. State taxes will not be withheld on a lump sum distribution of a death ben-efit payable under an annuity contract, unless requested.

* Residents of New York may elect withholding on distributions from Annuities only.


of 2 State Income Tax Withholding Disclosure FR2070-US 0720

State Withholding Requirements continued • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •If Withholding Applies

State For non-periodic (i.e non-annuitized) payments For periodic (i.e. annuitized) payments

Alabama, Colorado, Hawaii, Idaho, Kentucky, Louisiana, Mississippi, North Dakota, Ohio, Pennsylvania, Rhode Island, Utah or West Virginia

Will be the amount requested

Arizona N/AYou may choose from the following rates: 0.8%, 1.3%, 1.8%, 2.7%, 3.6%, 4.2%, and 5.1%. You may also request additional withholding.

Arkansas Must be at least 3% of the taxable amountWill be 5% on eligible rollover distributions

Will be calculated as if the payment were wagesWill be 5% on eligible rollover distributions

California Must be at least 10% of the federal withholding amount

ConnecticutMust be at least 6.99% of the taxable amount, unless you claim exemption (may not claim exemption from lump sum distribution)

Will be calculated as if the payment were wages, unless you claim exemption

Delaware, Iowa or Massachusetts Must be at least 5% of the taxable amount

District of Columbia

• Will be 8.95% on full surrenders of a qualified contract

• Will be the amount requested for all other distributions

Will be the amount requested

Georgia Must be at least as much as would be withheld if the payment were wages Will be calculated as if the payment were wages

Illinois N/A Will be the amount requested

Indiana, Missouri, Montana, New Jersey or New Mexico Must be at least $10

Kansas, Maine, Nebraska or Oklahoma Must be at least 5% of the taxable amount

Will be calculated as if the payment were wages. In Nebraska, except for eligible rollover distribu-tions, must be at least 5% of the taxable amount.

Maryland • Will be 7.75% of the taxable amount for eligible rollover distributions from qualified contracts.• Must be at least $5 for all other payments.

Michigan Must be at least 4.25% of the taxable amount

Minnesota or South Carolina Will be calculated as if the payment were wages

New York or Wisconsin Must be at least $5

North Carolina or Virginia Must be at least 4% of the taxable amount Will be calculated as of the payment were wages

Oregon Must be at least 8% of the taxable amount Will be calculated as if the payment were wages

Utah Will be the amount requested Will be calculated as if the payment were wages

Vermont Must be at least 30% of the federal withholding amount Will be calculated as if the payment were wages

your death benefit will be reduced

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