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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.) a distribution following the death of a plan participant (use the Beneficiary election Form.)

Beneficiary Election Form.) govnp • installment payments (if your Plan allows, use the . Systematic Withdrawal/Installment Payment Option Request Form.) • an annuity (if your Plan offers annuity payments, use the . Annuity Request Form.) • a hardship withdrawal (if your Plan allows, use the . Hardship Withdrawal Request. Form.)

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Transcription of Withdrawal Request Form - MassMutual

1 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.) a distribution following the death of a plan participant (use the Beneficiary election Form.)

2 Installment payments (if your Plan allows, use the Systematic Withdrawal /Installment Payment Option Request Form.) an annuity (if your Plan offers annuity payments, use the Annuity Request Form.) a hardship Withdrawal (if your Plan allows, use the hardship Withdrawal Request Form.) Direct Rollovers and Transfers: A LETTER OF ACCEPTANCE (LOA) FROM THE RECIPIENT PROVIDER IS REQUIRED. LOA's must be received prior to or along with this form in good order. If applicable, the LOA from the recipient provider must specifically state that they will accept Roth money. MassMutual Retirement Services will not process this form until it is received in good order. Please see the Important Information Section for information on "Good Order" DISTRIB NE-438-16 Rev Page 1 of 6 B - Participant Information * Legal AddressStateZip CodeCitySSNP articipant NameDate of Birth*We will change your account information to reflect the Legal Address above and all future mailings will be sent to this address unless changed by you or your Plan Administrator as described under "Stale Address" in the Important Information Phone NumberQuestions?

3 Call MassMutual s Customer Service Center 1-800-528-9009 Fax 877-526-2531 or 800-678-8645 Online Section A - Plan Information (required) Plan NameGroup of Iowa 403(b)750923 EmailSection D - Payment Amount (Participant completes, if applicable)403 DISTRIB NE-438-16 Rev Page 2 of 6 C - Reason for Distribution I hereby elect my account balance be distributed as a: (Make a selection in 1 or 2 below)Lump Sum full distribution of $Directly roll over or Transfer my entire account (whole percentages only) and%orPay me a Cash Payment of my account: $%pay to me the remaining account balance in a Cash roll over or Transfer the remaining account Direct Rollover or Transfer of my account: $(whole percentages only) and%or(whole percentages only) and leave the remainder of my %orleave the remainder of my account in the Plan (if Plan permits).

4 Please be aware that when requesting a specific dollar amount that you take into consideration that the payment will be reduced by all applicable federal and state income taxes. See Source of Payment for Partial Withdrawals, Section in the Plan (if Plan permits).Partial Direct Rollover or Transfer of my account: $Cash Payment to me: (Select one below)Direct Rollover or Transfer to the institution named in Direct Rollover or Transfer Payment Instructions, Section F (Select one below). Check with your Plan and financial institution for minimum be aware that when requesting a specific dollar amount that you take into consideration that the payment will be reduced by all applicable federal and state income taxes. See Source of Payment for Partial Withdrawals, Section E.(whole percentages only) andIf the Plan permits, you may take a Withdrawal for one of the following reasons without further verification from the Authorized Plan Administrator: Withdrawal of rollover sourceAttainment of age 59 Attainment of Plan's Normal Retirement AgeWithdrawal of traditional after-tax sourceTransfer to purchase Permissive Service Credit under a defined contribution planONLY SELECT ONE REASON AND PROVIDE A DATE IF REQUESTED Severance from employment (Date) If a Withdrawal is being requested for one of the above reasons, the Employer or Authorized Employer Representative must confirm the reason checked above for this Request to be considered in good order.

5 I certify that the reason selected above has occurred. If an Eligible Housing Withdrawal is selected in Section H; to the best of my knowledge the participant is eligible to receive a housing allowance. Check with your legal counsel to determine if the participant is eligible. Direct payment of Qualified Health Insurance Premiums (refer to the Important Information Section for details.) _____ _____ Authorized Plan Administrator s Signature Date _____ Authorized Plan Administrator s Name (please print) Disability, as defined by the Plan (Date) Termination/ Retirement Date Retirement (Date)Beneficiary (there must be an existing account for this beneficiaryFor a QDRO indicate if the Alternate Payee is a:Spouse or Former SpouseQDRO Alternate Payee (there must be an existing alternate payee account).)

6 Non-Spouse - The participant must also complete a Non-Spouse Withholding Authorization Form. Section F - Payment Instructions (If requesting a Direct Rollover, Transfer to purchase Permissive Service Credits, or Direct payment to Insurer for Qualified Health Insurance account only ( , pre-tax, after-tax* and employer contributions) to a: (Select one)Traditional IRAE ligible Retirement Plan*If your account includes after-tax contributions, do you want to directly roll it over to the eligible retirement plan (that accepts after-tax rollovers) or Traditional IRA below?(If no choice is made, your after-tax contributions will be paid to you in a separate check.)NoYesFinancial Institution Name for Non-Roth RolloversFinancial Institution Name for Roth Roth account only to one of the following: (Select one) Eligible Retirement Plan that accepts Roth rolloversRoth IRANote: If your account includes Roth contributions and you have elected a distribution of your entire account in Section D you must name a Financial Institution above or your Roth contributions will be made payable to you in a separate check.)

7 403 DISTRIB NE-438-16 Rev Page 3 of 6 Institution AddressFinancial Institution AddressAccount No.(Default if no election is made, your after-tax contributions will be distributed to you in a separate check.)NoYesNon-Roth account only to a Roth IRA ( , Roth Conversion). I understand that the taxable amount paid from my non-Roth account will be reported on IRS Form 1099-R as taxable income and that I may elect voluntary federal withholding on this amount in Section H, which may be subject to a premature distribution penalty. You should consult with your tax advisor before making this election . *If your account includes after-tax contributions, do you want to directly roll it over to your Roth IRA? Institution Name for Roth IRA for ConversionFinancial Institution AddressAccount hereby elect to directly roll over my distribution to: (Complete all sections that apply.)

8 A LETTER OF ACCEPTANCE (LOA) FROM THE RECIPIENT PROVIDER IS REQUIRED. LOA's must be received prior to or along with this form in good order. If applicable, the LOA from the recipient provider must specifically state that they will accept Roth 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 70 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:Section E - Source of Payment for Partial Withdrawals If you requested a partial Withdrawal from your vested account, your payment will be processed pro-rata across all of your contribution sources and investments unless Special Instructions are provided below.

9 Roth Contribution Source election : If your account contains Roth contributions/rollovers you may, but are not required to, elect a percentage to be taken from the Roth source(s) to satisfy your partial Withdrawal . I hereby elect MassMutual to take (whole percentage) of my Roth contribution source(s). I understand that if this percentage does not fulfill my Withdrawal Request , the remaining portion will be taken pro-rata from all other contribution sources. (Default is zero percent (0%) from your Roth contribution source(s) if no election is made.)%3. Direct payment to Insurer for Qualified Health Insurance Premiums Please indicate the insurer or group health plan for qualified health insurance premiums and the mailing NameZip CodeStateCityMailing AddressAttention403 DISTRIB NE-438-16 Rev Page 4 of 6 G - Delivery Instructions (Participant completes, if applicable)Mailing AddressZip will mail a check to you at the legal address provided in Section B unless you select an alternative mailing address below.

10 Note: Checks will be mailed within seven days after the processing Crediting Instructions/ participant's account number Wire transfer my payment. I understand that a $ fee will be deducted from my distribution for this service; your financial institution may also charge a fee. Note: Your wire will be delayed if you provide invalid wire instructions or account numbers. Wire Capable ABA No. As some ABA routing numbers are NOT federal wire capable, please be sure to check with your financial institution for proper wire instructions. Wires to Credit Unions may take more time and have more detailed instructions. You may include detailed wire instructions below or attach them to this on Account (must include participant's name)You may also select other means for receiving your distribution.


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