Income Payment Information Change Request Use this form to designate payees, update your tax withholding election, and/or set up an Electronic Fund Transfer. If you have not previously provided payee information, your annuity payment will be mailed to the Contract Owner, at the address of record. If you have not previously updated your tax withholding election, a default tax withholding of married with three exemptions will be made. If you need additional information, contact your personal financial representative, tax advisor or the MassMutual Customer Service Center at 1-800-272-2216 (Monday through Friday, 8am 8pm Eastern Time). Print clearly in CAPITAL letters and skip a box between words Report dollar amounts with commas, decimals and cents $ 1 5 E L M S T 1 2, 3 5 6. 0 0 A Contract Information : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : 1. Contract/policy/payee number: 2. Owner full legal name: 3. Phone number: 4. Email address (jdoe@xyz.com): - - ext. Home Cell Work B Payee Information : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : Indicate all payees and the payment amount or percentage designated to each. Payments will be sent to the payee by check unless section C Bank Information is complete. 1. Owner: % OR $. 2. Joint Owner: % OR $. 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. page 1 of 4 Income Payment Information Change Request FR2076-AN 0516
B Payee Information continued 3. Alternate Payee 1: % OR $. a. Full legal name (First, MI, Last, Suffix): b. Street: c. City: d. State: Zip: - e. Social Security Number (SSN) or Taxpayer Identification Number (TIN): SSN TIN 4. Alternate Payee 2: % OR $. a. Full legal name (First, MI, Last, Suffix): b. Street: c. City: d. State: Zip: - e. Social Security Number (SSN) or Taxpayer Identification Number (TIN): SSN TIN C Bank Information : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : Complete if you would like to receive payments through Electronic Fund Transfer (EFT). To help protect our customers assets, MassMutual will independently validate bank and customer account information before processing an EFT/Direct Deposit. If we are unable to independently validate the bank and customer account information or sufficient documentation to support the EFT/Direct Deposit is not provided, we will mail a check to the Owner at the address of record via U.S. Postal Service First Class Mail. It should be noted that we are not always able to independently validate credit unions or smaller banks. Refer to EFT Terms & Conditions in section - E Agreements & Signatures. 1. Bank account type (Select one): Checking (Attach a voided check or signed specification (spec) sheet/letter of instruction from the bank) Savings (Attach a signed specification (spec) sheet/letter of instruction from the bank) The account holder name on the voided check or signed spec sheet/letter must match the payee. Deposit slips and starter checks will not be accepted. page 2 of 4 Income Payment Information Change Request FR2076-AN 0516
D Withholding Election : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : Payments qualifying as eligible rollover distributions, which you receive from tax-qualified contracts, are subject to mandatory 20% federal income tax withholding. The Internal Revenue Code requires you receive a reasonable time (at least 30 days) to consider making a direct rollover of your tax-qualified assets to an eligible retirement plan rather than receiving an eligible rollover distribution subject to mandatory withholding. You may elect to waive the right to this required time period. 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 included in your income subject to Federal income tax and will be like wage withholding. There will be no withholding on the return of your own nondeductible contributions to the contract. Any election you make will remain in effect until you revoke it by returning to us a signed and dated revocation of election. If no withholding election is affirmatively made, withholding will be performed based on a filing status of married with three exemptions as required by the Internal Revenue Code. 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. 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 the 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 for payments other than eligible rollover distributions: I elect to have no income tax withheld from my annuity payments (Skip to section E Agreements & Signatures). I want my federal withholding from each annuity payment to be figured using the default assumption of married claiming three exemptions unless another election of allowances and marital status is shown below (Complete question 3 to designate an additional amount, if applicable). Allowances Single Married Married, but withhold at a higher single rate. Withhold the following additional amount from each annuity payment (Complete question 2). $. E Agreements & Signatures : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : Review and sign. A signature is required to process your request. If indicated in section C Bank Information, I authorize MassMutual to deposit, by Electronic Fund Transfer (EFT), income payments payable under the contract to the designated bank account. Payments made under this authorization will fully satisfy MassMutual s obligation to make payment to me. I also authorize MassMutual to debit the designated bank account to recover any overpayments made to me. EFT Terms & Conditions: 1. MassMutual shall incur no liability as a result of a deposit being dishonored by your bank. This authorization shall not impose any legal obligation on MassMutual to make such deposits. 2. A voided check or Specification ( Spec ) Sheet/Letter of Instruction from the banking institution must be included with this form. 3. The name displayed on the voided check or Specification ( Spec ) Sheet/Letter of Instruction from the banking institution must match the payee. For example, if the payee is a trust or an estate, deposits cannot be made into a trustee or executor s personal account. 4. Starter checks will not be accepted unless accompanied by a Specification ( Spec ) Sheet/Letter of Instruction from the banking institution. 5. Deposit slips will not be accepted. 6. EFT is only available for United States-based banks or participating credit unions. No foreign banking institutions are allowed. page 3 of 4 Income Payment Information Change Request FR2076-AN 0516
E Agreements & Signatures continued Owner s Social Security Number (SSN) or Taxpayer Identification Number (TIN): SSN TIN By my signature, I certify under penalties of perjury that: (1) the number shown above is my correct Taxpayer Identification Number; (2) I am not subject to backup withholding; and (3) I am a U.S. person (including U.S. resident alien). 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. Signature of Owner: Signature of Joint Owner (If applicable): Signature of Authorized Account Holder (If applicable): Signature of Additional Authorized Account Holder (If applicable): F Notary Public Stamp : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : A Notary Public stamp is not required if the check is made payable to a financial institution that has provided a letter of acceptance. A Notary Public stamp is required for the Owner and Owner s spouse (if applicable) when: (1) checks/eft are paid or sent to someone other than the owner at the address of record; or (2) proceeds are sent to an address that has been changed in the past 30 days. A Notary Public stamp can be obtained from most banks and credit unions. Faxes will be accepted if a Notary signature is present. Subscribed and sworn to before me this Signature of Notary Public: My commission expires: day of Affix stamp/seal G Submission & Contact Information : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : For more information or general questions, use the resources below. Once you have reviewed and completed the form, return pages 1-4 for processing. We will only accept responsibility for forms that are submitted as indicated below. Phone: 1-800-272-2216 Monday through Friday, 8 a.m. 5 p.m. Eastern Time Mail: MassMutual Annuity Service Center Hub PO Box 9067 Springfield, MA 01102-9067 Mail: MassMutual Annuity Service Center Hub 1295 State Street Springfield, MA 01111-0001 Fax: 1-866-329-4272 Retain this original and the fax machine confirmation statement for your files. Email: ANNfax@massmutual.com page 4 of 4 Income Payment Information Change Request FR2076-AN 0516
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... 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 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. page 1 of 1 State Income Tax Withholding Disclosure FR2070-US 0316