[plan name] direct rollover formdirect rollover – this form provides for the transfer of assets...

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f6826as457nenatrsep COMPLETE ALL PAGES Return to: MassMutual, PO Box 219062, Kansas City MO 64121-9062

For Overnight Mail: MassMutual, 430 W 7th St, Kansas City MO 64105 RS-42352-02 EXP 03/01/2021

[PLAN NAME] DIRECT ROLLOVER FORM

457(b) Governmental Plan Account Number [__________]

Direct rollover – This form provides for the transfer of assets from one qualified retirement plan or IRA directly to another qualified retirement plan or IRA. Your distribution will be made payable directly to your new account for your benefit. No taxes will be withheld from your rollover amount.

Section A: PARTICIPANT INFORMATION (Participant Completes) Name: ____________________________________________________ first middle last Address: _____________________________________________________________ street

_____________________________________________________________ city state zip Telephone No: _________________________ E-mail Address: _________________________________ Birth Date: ____________________ Date of Hire: ____________________ mm/dd/yyyy mm/dd/yyyy Social Security No. __________________ Marital Status: Married Not Married or Legally Separated Payroll Frequency: monthly (12/yr) semi-monthly (24/yr) bi-weekly (26/yr) weekly (52/yr)

Name of Prior Plan _____________________________________________________________________________ Name of Prior Financial Institution _________________________________________________________________ Total Amount of Rollover from 457 (b) governmental plan: $________________ Total Amount of Rollover from 401(a) qualified plan, 403(a) qualified annuity plan, 403(b) plan or traditional IRA: $________________ Note: Rollovers cannot include required minimum distributions or participant after-tax contributions.

Section B: TAX INFORMATION (Participant Completes) - applies to assets other than a Roth Account (Consult your Plan Administrator as to what types of money are allowed to be rolled over.)

For assistance with your Rollover, please contact MassMutual’s Concierge Roll-In Service Team by calling 1-888-526-6905 between 8:00 AM and 8:00 PM EST, Monday through Friday. Working with this Concierge team may eliminate the need to complete this form.



Section B: ROTH ROLLOVER INFORMATION (Participant Completes) (Consult your Plan Administrator as to what types of money are allowed to be rolled over.)

Name of Prior Plan _____________________________________________________________________________ Name of Prior Financial Institution _________________________________________________________________ Amount of Rollover: Roth Contributions (basis*) $________________ Roth Earnings $________________ Total Rollover $________________ Note: Roth Contributions can only be rolled over as part of a direct rollover from a Roth 457(b) plan, Roth 403(b) plan or Roth 401(k) plan. Roth IRA Contributions cannot be rolled over to a Roth 457(b) plan. *Basis represents the amount of accumulated contributions that have already been taxed. Contact your prior provider or refer to the distribution confirmation received from your prior provider for this amount. Roth Rollover Information: Complete only one. This is a Roth qualified distribution (I am at least 59½, or the distribution is the result of death or disability and the

required 5-taxable-year period was satisfied.) The Roth contribution start date is: ______________ (Enter first taxable year in which Roth contributions were made

or based upon a previous rollover contribution, if earlier.)

Section C: CERTIFICATION INFORMATION (Participant Completes)

I certify that to the best of my knowledge, the funds being rolled over consist entirely of an eligible rollover distribution from one of the following types of Plans:

An employer retirement plan qualified under Code Section 401(a) (e.g. defined contribution plans such as 401(k), profit sharing, money purchase, and target benefit plans; defined benefit plan)

A qualified annuity plan under Code Section 403(a) A custodial account or tax-sheltered annuity qualified under Code section 403(b) A governmental plan qualified under Code Section 457(b) Pre-tax rollover amounts from traditional or conduit IRAs qualified under Code Section 408(a) and 408(b)

I certify that this distribution is not (a) one of a series of substantially equal payments over my life or single life expectancy or the joint life expectancies of myself and my designated beneficiary; (b) one of a series of installment payments payable over 10 years or more; (c) all or part of a required minimum distribution; (d) a distribution due to a financial hardship; (e) a return of any excess deferrals, excess contributions, excess aggregate contributions or excess annual additions made to the plan; (f) a deemed distribution due to a loan default; or (g) a death benefit paid to a non-spouse beneficiary.

I hereby authorize MassMutual to contact me, the Financial Institution Representative, or Plan Administrator listed on this form if they have any questions or require further documentation to process this rollover transaction.

Attach one of the following items. Your Rollover will not be processed/invested into the plan without this information.

Letter of Determination from prior plan Statement of account from prior plan that reflects the type of plan the funds are being rolled out of (for example: 401k,

403(b), IRA as allowed by your plan) Certification of Prior Plan Administrator or IRA Trustee/Custodian (Completed in Section D below) Other proof of the prior plan’s qualification status (i.e. letter from prior plan or provider) If unable to provide any of the above items, please contact the MassMutual Concierge Service Team at 1-888-526-

6905 between 8:00 AM and 8:00 PM EST, Monday through Friday for assistance.

_______________________________________________________________ ____________________ Employee Signature Date



Section D: CERTIFICATION OF PRIOR PLAN ADMINISTRATOR OR IRA TRUSTEE/CUSTODIAN (Complete only if selected in Section C above) Certification by IRA Institution or for direct and indirect rollovers; Certification by Prior Employer’s Plan Administrator for indirect rollovers. This section must be completed by the trustee (or custodian) of the traditional IRA or by the administrator of the eligible employer plan from which the distribution was distributed. 1. The Plan Administrator or Custodian of your Prior Plan must complete the certification below if this rollover is an indirect

rollover or a direct rollover from a traditional IRA. 2. Evidence of the date of Distribution from your Prior Plan or IRA must be provided if the funds are not coming directly from

your Prior Plan or IRA, e.g. copy of the original distribution confirmation statement or check stub. Certification of Prior Plan Administrator or IRA Trustee/Custodian I, as the Plan Administrator or Trustee/Custodian of the above Plan or IRA, certify that the funds have been distributed from an eligible retirement plan intended to satisfy the requirements of Internal Revenue Code Section 401(a) 403(a) 403(b) 457(b) or IRA qualified under 408(a) and 408(b). I am unaware of any Plan provision or operation that would disqualify the Plan. ________________________________________________________________________ Type or print name of Financial Institution Representative or Prior Plan Administrator _____________________________________________________________________ _______________________ Signature of Prior Plan Administrator or Trustee/Custodian Date ____________________________________________________________________ (____)__________________ Name of Institution Contact Phone Number _____________________________________________________________________________________________________ Address Section E: INVESTMENT SELECTION (Participant Completes) Check one box only For more complete information about each investment, including charges and expenses, we recommend that you read each investment’s prospectus carefully before investing. You can read and print copies for all of your plan’s investment options through the RetireSMARTSM participant website at www.retiresmart.com. You also may contact our Participant Information Center at 1-800-743-5274 between 8:00 am and 8:00 pm ET, Monday through Friday, to request a prospectus. The Rollover Contributions will be invested separately from any other contributions to the Plan. Please be aware, if you are currently invested in a CustomChoice Strategy and you change your investments, you will no longer be invested in the strategy. Note: If you do not make investment selections, if the selections are incomplete, or if the percentages listed do not total 100%, the entire rollover amount will be invested in your current rollover investment selections. If you do not have rollover investment selections on file, the rollover will be invested in the Plan’s default investment option(s). Invest my rollover the same as current rollover investment selections on file Invest my rollover in the Plan default investment option Invest my rollover in the investment selections below



(ENTER WHOLE PERCENTAGES; 1% MINIMUM IN INVESTMENTS SELECTED; MULTIPLES OF 1% THEREAFTER)

Fund Rollover Contribution Fund Rollover Contribution

______ % ______ % ______ % ______ % ______ % ______ % ______ % ______ % ______ % ______ % ______ % ______ % ______ % ______ % ______ % ______ % ______ % ______ % ______ % ______ % ______ % ______ % ______ % ______ % ______ % ______ % ______ % ______ % ______ % ______ % ______ % ______ % ______ % ______ % ______ % ______ % ______ % ______ % ______ % ______ % ______ % ______ % ______ % ______ % ______ % ______ % ______ % ______ % ______ % ______ %

(TOTAL PERCENTAGES MUST EQUAL 100%)

Copyright © 2018. All rights reserved. Massachusetts Mutual Life Insurance Company (MassMutual), Springfield, MA 01111.

1 RS-42352-02 EXP 03/01/2021

Instructions to Complete Direct Rollover Form

Read through these instructions before completing this request If you have NOT started the Rollover process, please contact the Concierge Roll-In Team at 1-888-526-6905

between 8:00 AM and 8:00 PM EST Monday through Friday for assistance with the Rollover process If you have started the Rollover process and have questions while completing this request, please contact the

Participant Information Center at 1-800-743-5274 between 8:00 AM and 8:00 PM EST, Monday through Friday

Incomplete or illegible forms may delay processing of your request When submitting the form, do not include these instructions Use this form for direct rollovers only. For indirect rollovers, the form can be found on www.retiresmart.com under Forms.

Section A: Participant Information To be completed by the Participant Did you fill out the participant information completely? Is it legible?

Section B: Tax Information/Roth Rollover Information To be completed by the Participant NOTE: If you are unsure of the tax breakdown of the funds, please consult your prior financial provider before completing the form.

Important Definitions: Prior Provider: where your assets were previously held prior to this Rollover Pre-Tax Contributions: assets deducted from your gross wage before taxes Earnings: income earned from your contributions Roth Contributions: assets funded with after-tax money. Distributions and earnings are tax-free provided the contributions have been invested for at least 5 years and you have reached age 59½ (or if made after death or disability)

Did you fill out your rollover funds’ taxability? If you are rolling over Roth funds, did you provide a breakdown of contributions and the funds earned

(earnings)? If you are rolling over Roth funds, did you provide the start date of the first Roth contribution?

Section C: Certification Information To be completed by the Participant Did you (the participant) sign and date the form? Did you (the participant) attach one of the required documents to certifying the prior plans qualification

status? If unable to provide any of the items, please contact the MassMutual Concierge Service Team at 1-888-526-6905 for assistance.

Section D: Certification of Prior Plan Administrator or IRA Trustee/Custodian To be completed by the trustee (or custodian) of the traditional IRA or by the administrator of the eligible employer plan from which the distribution was distributed Did you (the Prior Plan Administrator or Trustee/Custodian) select the type of eligible retirement plan

the assets were previously held in prior to this Rollover? Did you (the Prior Plan Administrator or Trustee/Custodian) print your name, and sign and date the form? Did you (the Prior Plan Administrator or Trustee/Custodian) enter the name and address of your financial

institution and your telephone number in section D of the form?

2 RS-42352-02 EXP 03/01/2021

Section E: Investment Selection To be completed by the Participant Did you review the instructions on the Direct Rollover Form to confirm you selected an Investment Selection

allowed by your plan? Did you select an Investment Option on the Direct Rollover Form?

After you complete the Direct Rollover Form: Mailing Information After you have completed your Direct Rollover Form, please submit the form in one of the following ways: Mailing Address:

MassMutual PO Box 219062 Kansas City MO 64121-9062

OR Overnight Mail: MassMutual 430 W7th St Kansas City MO 64105

OR Email: [email protected]

mailto:[email protected]

[plan name] direct rollover formdirect rollover – this form provides for the transfer of assets...

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