Tax Sheltered Annuity (TSA) Conversion

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1 Tax Sheltered Annuity (TSA) Conversion Use this form for conversions from the following contract types: TSA contracts, Keogh (H.R. 10) Plans, former Qualified Plan (individually-owned) contracts Use this form to request a conversion of your contract to a Traditional IRA, Roth IRA or SEP IRA. After reading section G Disclosures, complete all sections of this form, unless otherwise indicated, sign and return. Do not complete this request to convert without consulting your financial advisor and qualified tax advisor. For additional information, contact your personal financial representative, tax advisor or the MassMutual Customer Service Center at A Owner/Participant Information : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : 1. Contract/Certificate number(s): 2. Owner/Participant name: 3. Taxpayer Identification Number (SSN/ITIN/EIN): 4. Phone number: ( ) - Extension: Home Work Mobile 5. address: B Conversion Information : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : Outstanding loans will be paid in full before the conversion is completed. Not all market types are available with all products. Refer to the prospectus for additional information. 1. New market type election (Select one): Traditional IRA SEP IRA Roth IRA (A conversion to a Roth IRA is a taxable event and you will be liable for any applicable taxes due to the conversion. We recommend that you consult your financial advisor and a qualified tax advisor before converting. If the existing contract is a TSA Artistry contract, a conversion to a Roth IRA is not permitted without opening a new non-artistry contract.) 2. Conversion eligibility reason (Select one reason for your existing contract type): TSA* Texas ORP** Keogh (H.R. 10) Attainment of age 59½ Attainment of age 70½ Plan termination Severance from employment Severance from employment Plan termination Employer contributions & earnings * Plan Administrator signature may be needed in section E Plan Administrator Certification. Contact your Plan Administrator for further guidance. See section G Disclosures for exception guidelines. ** May not be available for all products. Refer to the prospectus for details. Prior to any surrender, MassMutual must receive written acknowledgment of the surrender from the applicable Texas public institution of higher education. Available only for MassMutual Artistry and Flex contracts. Contracts issued on or after 1/1/09 require either Plan approval or a different eligibility reason. C Withholding Election & Tax Reporting Information : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : Complete this section for conversions to Roth IRA only. A conversion into a Roth IRA will subject the Fair Market Value (FMV) of the contract being converted to income tax. Generally, the FMV is equal to the cash value (without surrender charges) of the contract value. However, if the contract has an additional benefit, such as death benefit or guaranteed withdrawal benefit, the FMV of the contract may be significantly greater than the cash value. Generally, the additional 10% tax on premature distributions will not apply to the amount converted at the time of conversion. However, if part of the converted amount is used to pay tax on the conversion through withholding or otherwise, that portion will be subject to the 10% additional tax if the individual is under 59½ years old. Payments you receive from MassMutual Life Insurance Company ( MassMutual ) are subject to federal income tax withholding unless you elect not to have withholding apply. If your contract is subject to surrender charges, withholding for purposes of this conversion may be subject the amount withheld to surrender charges. Any election you make will remain in effect until you revoke it by returning to us a signed and dated revocation of election. Once a payment has been made, the withholding election applicable to that payment cannot be changed. Massachusetts Mutual Life Insurance Company (MassMutual), 1295 State Street, Springfield, MA and its subsidiaries: C.M. Life Insurance Company and MML Bay State Life Insurance Company, 100 Bright Meadow Boulevard, Enfield, Connecticut page 1 of 6 Tax Sheltered Annuity (TSA) Conversion 0416 FR1212-AN

2 C Withholding Election & Tax Reporting Information continued 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 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. 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. Check the appropriate box below to make your withholding election. If no withholding election is affirmatively made, no tax will be withheld. Do not withhold (Default) Withhold 10% Withhold more than 10% (Specify): % Contact our Customer Service Center at to obtain a FMV estimate on your variable contract. D Agreements & Signatures : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : By signing below, I, the Owner/Participant, certify that I have read this form and that the information and elections made above are accurate. I 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. I hereby request that any provisions of the contract that are inconsistent with the conversion status be removed and replaced with those provisions necessary to qualify the contract as converted in section B Conversion Information. Taxpayer Certification. By my signature, I, the Owner/Participant, certify under penalties of perjury that: (1) the number shown in section A 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. Marital Status. (Required for all TSA, Keogh (H.R. 10) and former Qualified Plan (individually-owned) contracts). By my signature below, I, the Owner/Participant, certify that I am (Select one): Single, divorced/legally separated, widowed or unable to locate my spouse. Married and my Plan is not subject to ERISA (Consult with your employer if you are uncertain whether your Plan is subject to ERISA). Married and my Plan is subject to ERISA (Signature of spouse and Notary stamp/seal also required). Signature of Owner/Participant: Printed name: Date: Spousal Consent & Notary Stamp/Seal (Required for ERISA TSA, Keogh (H.R. 10) and former Qualified Plan (individually-owned) contracts) I, the Owner/Participant s spouse, hereby consent to the Owner/Participant s election to receive a distribution from the Tax Sheltered Annuity, Keogh (H.R. 10) Plan or former Qualified Plan (individually-owned) contract. I understand and acknowledge that I am waiving any legal right to this distribution as part of any death benefit payable from this contract. Signature of Spouse: Printed name: Date: 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: Affix Notary State/County where signed: Stamp/Seal My commission expires (mm/dd/yyyy): page 2 of 6 Tax Sheltered Annuity (TSA) Conversion 0416 FR1212-AN

3 E Plan Administrator Certification : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : Complete for TSA contracts only. By signing below as the Plan Administrator, I am aware that the Plan Participant is requesting a distribution and I am certifying to MassMutual that the employee is eligible to receive this distribution as indicated in section B Conversion Information. Plan Terminations: If the Plan has terminated, the Plan Administrator certifies that the 403(b) Plan named below has been terminated in accordance with regulation Section 1.403(b)-10 and meets the requirements to allow all Participants under the Plan to be eligible to take a distribution. Signature of Plan Administrator: Printed name: Date: Plan name: Plan contact name (First, MI, Last, Suffix): Plan contact phone number: ( ) - Extension: Plan contact address: F Submission & Contact Information : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : For more information or general questions, use the resources below or visit Once you have reviewed and completed this form, return pages 1-3 for processing. We will only accept responsibility for forms that are submitted as indicated below. Phone: Monday through Friday, 8 a.m. 8 p.m. Eastern Time Mail: MassMutual Attention: Annuities PO Box 9067 Springfield, MA Fax: Retain this original and the fax machine confirmation statement for your files. ANNFax@massmutual.com G Disclosures : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : Conversion Eligibility In order to request a conversion, you must determine your eligibility. The Tax Reform Act of 1986 (TRA 86) placed certain restrictions on distributions from TSA Plans. The restrictions are meant to ensure that the qualified contract is being used as a vehicle for tax-deferred savings for retirement. In addition, if you have an outstanding loan on a TSA, other restrictions may apply. Conversion Eligibility Reason. Conversions can be made under the following circumstances: Attainment of age 59½ Attainment of age 70½ for Texas Optional Retirement Programs Severance from employment or amounts attributable to a prior employer Plan termination. Your 403(b) Plan sponsor has notified us that they are no longer offering a 403(b) Plan, and that they have taken action that they deem to have terminated the Plan. Employer contributions and earnings (Available for MassMutual Artistry and Flex contracts only). Final TSA regulations provide that the distribution of employer contributions from TSA contracts issued on or after 1/1/09 must be restricted based on a stated events rule. This means that a TSA Plan must provide under its Plan document some specific restriction which must be met by the employee before employer contributions may be removed from the Plan. This restriction may take the form of attainment of a certain age or the completion of a fixed number of years. Since each TSA Plan can determine its unique restrictions, individual Plan sign-off is required for the distribution of employer contributions issued on or after 1/1/09. Loan Information Loan Payoff using contract value. If your contract has an outstanding loan, we will deduct any outstanding debt from the contract value prior to processing the conversion. If the loan is in good standing, the loan payoff will be treated as a taxable distribution. The payoff of a loan with TSA contract value is treated as a distribution from the TSA Plan. Therefore, an eligible distribution reason (ex: 59½, or separation from service) must exist before a loan can be paid off with contract value. If you have an outstanding loan from the Plan, your Plan benefit may be offset by the amount of the loan, typically when your employment ends. The loan offset amount is treated as a distribution to you at the time of the offset and will be taxed (including the 10% additional income tax on early distributions, unless an exception applies) unless you do a 60-day rollover in the amount of the loan offset to an IRA or employer plan. Special Notice Regarding Rollover Options Rollover Options. The following information is provided because all or a portion of a payment you are receiving is eligible to be rolled over to an IRA or an 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. page 3 of 6 Tax Sheltered Annuity (TSA) Conversion 0416 FR1212-AN

4 G Disclosures continued General Information About Rollovers How 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 applies). Where may I roll over the payment? You may roll over the payment to either an 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, no spousal consent rules apply to IRAs 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. 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. 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). 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. 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 lives or joint life expectancy of you and your beneficiary) Required minimum distributions after age 70½ (or after death) Hardship distributions Corrective distributions of contributions that exceed tax law limitations Loans treated as deemed distributions (for example, loans in default due to missed payments before your employment ends) Cost of life insurance paid by the Plan Payments of certain automatic enrollment contributions to be withdrawn within 90 days of the first contribution The Plan Administrator or the payor can tell you what portion of a payment is eligible for rollover. If I don t do a rollover, will I have to pay the 10% additional income tax on early distributions? If you are under age 59½, you will have to pay the 10% additional income tax on early distributions for any payment from the Plan (including amounts withheld for income tax) that you do not roll over, unless one of the exceptions listed below applies. This tax is in addition to the regular income tax on the payment not rolled over. The 10% additional income tax does not apply to the following payments from the Plan: Payments made after you separate from service if you will be at least age 55 in the year of the separation Payments that start after you separate from service if paid at least annually in equal or close to equal amounts over your life or life expectancy (or the lives or joint life expectancy of you and your beneficiary) Payments made due to disability Payments after your death Corrective distributions of contributions that exceed tax law limitations Payments made directly to the government to satisfy a federal tax levy Payments made under a qualified domestic relations order (QDRO) Payments up to the amount of your deductible medical expenses Certain payments made while you are on active duty if you were a member of a reserve component called to duty after September 11, 2001 for more than 179 days Payments of certain automatic enrollment contributions requested to be withdrawn within 90 days of the first contribution. 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. In general, the exceptions to the 10% additional income tax for early distributions from an IRA are the same as the exceptions listed above for early distributions from a Plan. However, there are a few differences for payments from an IRA, including: There is no exception for payments after separation from service that are made after age 55. The exception for qualified domestic relations orders (QDROs) does not apply (although a special rule applies under which, as part of a divorce or separation agreement, a tax-free transfer may be made directly to an IRA of a spouse or former spouse). The exception for payments made at least annually in equal or close to equal amounts over a specified period applies without regard to whether you have had a separation from service. There are additional exceptions for (1) payments for qualified higher education expenses, (2) payments up to $10,000 used in a qualified first-time home purchase, and (3) payments for health insurance premiums after you have received unemployment compensation for 12 consecutive weeks (or would have been eligible to receive unemployment compensation but for self-employed status). Will I owe State income taxes? This information does not describe any State or local income tax rules (including withholding rules). page 4 of 6 Tax Sheltered Annuity (TSA) Conversion 0416 FR1212-AN

5 G Disclosures continued You may roll over to an IRA a payment that includes after-tax contributions through either a direct rollover or a 60-day rollover. You must keep track of the aggregate amount of the after-tax contributions in all of your IRAs (in order to determine your taxable income for later payments from the IRAs). If you do a direct rollover of only a portion of the amount paid from the Plan and a portion is paid to you, the portion rolled over consists first of the amount that would be taxable if not rolled over. For example, assume you are receiving a complete distribution of your benefit which totals $12,000, of which $2,000 is after-tax contributions. In this case, if you directly roll over $10,000 to an IRA that is not a Roth IRA, no amount is taxable because the $2,000 amount not directly rolled over is treated as being after-tax contributions. If you do a direct rollover of the entire amount paid from the Plan to two or more destinations at the same time, you can choose which destination receives the after-tax contributions. If you do a 60-day rollover to an IRA of only a portion of a payment made to you, the after-tax contributions are treated as rolled over last. For example, assume you are receiving a distribution of $12,000, of which $2,000 is after-tax contributions, and no part of the distribution is directly rolled over. In this case, if you roll over $10,000 to an IRA that is not a Roth IRA in a 60-day rollover, no amount is taxable because the $2,000 amount not rolled over is treated as being after-tax contributions. You may roll over to an employer plan all of a payment that includes after-tax contributions, but only through a direct rollover (and only if the receiving Plan separately accounts for after-tax contributions and is not a Governmental Section 457(b) Plan). You can do a 60-day rollover to an employer plan of part of a payment that includes aftertax contributions, but only up to the amount of the payment that would be taxable if not rolled over. If 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. 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 have an outstanding loan that is being offset. If you have an outstanding loan from the Plan, your Plan benefit may be offset by the amount of the loan, typically when your employment ends. The loan offset amount is treated as a distribution to you at the time of the offset and will be taxed (including the 10% additional income tax on early distributions, unless an exception applies) unless you do a 60-day rollover in the amount of the loan offset to an IRA or employer plan. If you were born on or before January 1, If you were born on or before January 1, 1936 and receive a lump sum distribution that you do not roll over, special rules for calculating the amount of the tax on the payment might apply to you. For more information, see IRS Publication 575, Pension and Annuity Income. 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 rescue squad or ambulance crew. If you roll over 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. However, the 10% additional income tax on early distributions will not apply (unless you take the amount rolled over out of the Roth IRA within 5 years, counting from January 1 of the year of the rollover). 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). If you are not the Plan Participant Payments after 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, and the special rule described under the section If you were born on or before January 1, 1936 applies only if the Participant was born on or before January 1, 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 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 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. page 5 of 6 Tax Sheltered Annuity (TSA) Conversion 0416 FR1212-AN

6 G Disclosures continued 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, see IRS Publication 3, Armed Forces Tax Guide. Withholding Election The term Eligible Rollover Distribution refers to any payment directly to the individual that may be deposited into another eligible retirement account within 60 days to avoid income taxes (but which may not). Eligible rollover distributions are subject to 20% withholding and the client is not able to elect out of withholding. A distribution taken before age 59½ may be subject to a 10% penalty. 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. Important Replacement Information. If you are considering replacing this contract, the proposed replacement 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) , Monday 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 above-signed is returning the contract or represents that the contract is not locatable and is either lost, stolen or destroyed. In return for MassMutual redeeming/surrendering the contract, each of us agrees to hold MassMutual harmless from all claims and liability resulting from the redemption/surrender of the contract. To the best of our knowledge, the contract has not been given to and is not in the possession of any other person. If the original or any duplicate contract is found, both it and any duplicate contract will be returned to MassMutual. This agreement shall be binding on the estate and other successors of each of us. 30 Day Notice. The Internal Revenue Code gives you a reasonable time (at least 30 days) to consider making a direct transfer of TSA assets to an eligible TSA or a direct rollover to a Traditional IRA, SEP IRA, Governmental 457(b) Deferred Compensation Plan, or Qualified Employee Benefit Plan rather than receiving an eligible rollover distribution subject to mandatory withholding. You may waive this right by signing section D of the form without modification. The Agreements & Signatures section must be dated and signed as certification that all information provided is true and accurate. Your signature indicates that you agree to the Terms and Conditions for TSA distributions outlined above. 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. Spousal Consent This section must be completed if your qualified annuity is subject to ERISA, as explained below. If you indicate that you are married, your spouse must sign where indicated, and the form must be notarized. The Employee Retirement Income Security Act of 1974 (ERISA) applies to certain arrangements established by employers for the purpose of providing retirement benefits or income deferral to employees. ERISA applies to some, but not all, qualified annuity contracts. If a qualified annuity contract is subject to ERISA, compliance with various requirements is necessary. Spousal consent is one such requirement. In particular, a qualified annuity contract that is subject to ERISA must provide that accrued benefits payable to a vested, married Participant who is alive at the time of the annuity starting date must be payable in the form of a qualified joint and survivor annuity, and that accrued benefits payable to a vested, married Participant who has died before the annuity starting date must be payable in the form of a qualified pre-retirement survivor annuity to the Participant s surviving spouse. The payment of benefits in any other manner generally requires spousal consent. Spousal consent is not required in the following situations: If there is no spouse; If it has been established that the spouse cannot be located; or If the Participant and his/her spouse are legally separated or divorced. If you check divorced/legally separated, you certify that this annuity is not part of the terms of the divorce/separation. If you check unable to locate spouse, you certify that you have obtained a court order demonstrating abandonment. Generally, a qualified annuity contract with minimal employer involvement is not subject to ERISA. Examples of minimal involvement include providing product information, withholding salary reduction contributions and forwarding such contributions to the appropriate issuer. In addition, participation by employees must be voluntary, all rights under an account must be enforceable solely by the employee, and the employer must receive no compensation other than compensation for reasonable expenses actually incurred in accordance with complying with the employees salary reduction agreements. Plan Administrator Certification Plan Administrator sign-off may be required for TSA distributions depending on the provisions of your TSA Plan. Contracts that fall under the grandfathered status of IRS Revenue Ruling will not require Plan Administrator sign-off. Your contract may be considered grandfathered if your contract was: A result of a transfer (TSA-to-TSA Exchange) prior to September 24, 2007 and there have been no contributions added to the contract; or Issued prior to January 1, 2005 and no contributions have been made for any Participant under your Employer TSA plan since January 1, page 6 of 6 Tax Sheltered Annuity (TSA) Conversion 0416 FR1212-AN

7 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 (Monday through Friday, 8am-8pm Eastern Time). State Withholding Requirements : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : If you are a resident of... Alabama, Colorado, Connecticut, 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 state income tax will... 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. Arkansas, California, Delaware, Iowa, Kansas, Maine, Massachusetts, Nebraska, North Carolina, Oklahoma, Oregon or Vermont be withheld if federal income tax is withheld. However, even if federal income tax is not withheld, you may request that state income tax be withheld. Arizona, Illinois District of Columbia Georgia Maryland Michigan Virginia will be 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. be 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. be withheld from periodic payments (i.e. annuitized payments). State income taxes will not be withheld from any other distributions, unless you request state income tax withholding. be withheld from eligible rollover distributions, if federal income tax is withheld. You may request withholding on distributions from qualified contracts and non-qualified Annuities. be withheld, unless you opt out of withholding by submitting form MI W4-P. 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. * Residents of New York may elect withholding on distributions from Annuities only. Massachusetts Mutual Life Insurance Company (MassMutual), 1295 State Street, Springfield, MA and its subsidiaries: C.M. Life Insurance Company and MML Bay State Life Insurance Company, 100 Bright Meadow Boulevard, Enfield, Connecticut page 1 of 1 State Income Tax Withholding Disclosure FR2070-US 0316

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