Withdrawal Request Form - MassMutual

Withdrawal Request Form403(b) Notary RequiredUse this form if you want to Request from your plan account: a cash payment a direct rollover of your vested account to another eligible retirement plan or IRA Withdrawal of rollover monies, if the plan permits transfer to purchase Permissive Service Credit under a governmental defined benefit plan, if the plan permits direct payment of Qualified Health Insurance Premiums, if the plan permits Do not use this form if you want to Request : your required minimum distribution (RMD) (use the Required Minimum Distribution Request Form.) a contract exchange or transfer to another provider within your Plan (if you plan allows, use the 403(b) Transfer or Exchange Out Form.)

1. Direct Rollover . Note: An RMD must be requested prior to the rollover if you are required to receive an RMD because you are retired and age 70½ or older or are a beneficiary. Please indicate the Financial Institutions to make the check(s) payable for the Direct Rollover transaction requested below. Special Instructions:

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  Direct, Instructions, Rollovers, Massmutual, Direct rollover

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