MassMutual Thrift Plan CASH WITHDRAWAL REQUEST

MassMutual Thrift Plan CASH WITHDRAWAL REQUEST

Withdrawals from the MassMutual Thrift Plan while you are actively under contract with MassMutual or affiliate (called "in-service withdrawals") may only be made in certain circumstances.

Please note: If you are currently on active military duty, please contact Retirement Services for a HEART Withdrawal Form.

Participant's Name ______________________ _______________________ _______________________________

First

Middle

Last

Mailing Address ____________________________________________________________________________________

Street

City

State

ZIP

State of Legal Residence _____________________________ If the State of Legal Residence is not provided, MassMutual will use

the state provided in the Mailing Address for state tax purposes.

Social Security Number _______________ Date of Birth ______________ Phone Number ____________________

month / day / year

SOURCE HIERARCHY

Withdrawals are made in the Source Hierarchy (order) below. If the amount requested exceeds the first available source, it will be withdrawn from the next source in that order until the m aximum requested withdrawal am ount is reached. Withdrawals from your account will be made pro-rata from all investment options currently in use under the Plan.

Roth 401(k)*

After-Tax Deferred Compensation (Agent only) Rollover from prior employer's plan (Roth) Rollover from prior employer's plan (non-Roth) DLB Profit Sharing ** AISP Co. Match /Co. Match 401(k) Account** *Roth 401(k) is the first in the Source Hierarchy only if you are over age 59?; otherwise Roth 401(k) is not available for inservice withdrawal. Roth 401(k) is also available for hardship withdrawals regardless of age.

**Participants under age 59? must submit an affidavit certifying the existence of financial hardship in order to withdraw from these sources of contributions. If you need a hardship withdrawal, please complete a Hardship Withdrawal Request form and provide the necessary documentation. Suspension penalties may apply.

WITHDRAWAL OPTIONS (Check only one box.) Four withdrawals are allowed per calendar year.

Gross Amount:

Withdraw $_____________ from my vested account balance(s). I understand that any income tax withholding will be deducted from this amount so that the check will be less than the amount entered above.

Net Amount:

Withdraw an amount from my vested account balance(s) so that after any income taxes withholdings have been deducted the check will be for $_____________.

Percentage (%):

Withdraw ____% from my vested account balance(s). I understand that any income tax withholding will be deducted from this amount so that the check will be less than the percentage entered above.

If the amount available is less than requested, I want to withdraw the amount available: Yes

No

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