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PARTICIPANT HARDSHIP STATEMENT

IMPORTANT: Use this form for hardship loans or hardship withdrawals when the “safe harbor”

determination of hardship is used by the Plan. If “facts and circumstances” method is used for approving withdrawal

of any contributions under the Plan, additional information would be necessary.

Do not submit this form to MassMutual.

Participant's Name _____________________________________________________________________________ first middle last

Social Security No. ________________________

HARDSHIP REQUEST

1. I request a of $______________ due to hardship for the following reason(s):

This form is not used for processing. We will process your withdrawal for the amount requested on the processing form.

Expenses for Medical Care for myself, my spouse, my dependent or primary beneficiary (as permitted under the plan).

Purchase of My Primary Residence excluding mortgage payments.

Tuition and Related Education Fees including room and board expenses, for the next 12 months

for post-secondary education for myself, my spouse, my dependent or primary beneficiary (as permitted under the plan).

Prevention of Eviction or Foreclosure on my primary residence.

Expenses for the Repair of Damage on my primary residence that would qualify for the casualty

deduction under IRC §165.

Payment for Burial or Funeral Expenses for my deceased parent, spouse, children, dependents or

primary beneficiary (as permitted under the plan).

Expenses and losses (including loss of income) incurred due to a federally declared disaster, as allowed by the plan, by the Federal Emergency Management Agency (FEMA), provided that the employee’s principal residence or principal place of employment at the time of the disaster was located in an area designated by FEMA for individual assistance with respect to the disaster.

If required by your plan, please attach documentation evidencing the expense for which this hardship is requested. Please see the Documentation Guidelines. Note: your plan may have different or additional documentation requirements. Please confirm any requirements with your plan sponsor applicable to your circumstances. If the expense is for someone other than the Participant, list the recipient and his or her relationship to the Participant on the expense document.

2. I request an additional amount to pay anticipated federal, state, or local income taxes or excise taxes due to

this distribution.

3. PARTICIPANT CERTIFICATION: I hereby certify, represent and agree that:

The withdrawal/ loan amount requested is not in an amount more than my financial need, due to the reason stated in item (1) above, after applicable tax withholding and penalties;

I have obtained all currently available distribution amounts available to me under this and any other plan of my plan sponsor/employer, including any in-service withdrawals from rollover and/or after tax employee contributions (in accordance with the plan document and applicable law). If there are additional amounts available for withdrawal under the plan other than for hardship reasons, I certify that such amounts (if any) have been paid to me prior to this request for a hardship withdrawal.

(check one)

withdrawal

loan

If my plan requires that I take all available participant loans (unless such loans would cause further hardship), I certify that, if so required, I have taken such loans prior to this request for a hardship withdrawal; and

I have insufficient cash or other liquid assets to satisfy the financial need for which I am requesting a hardship withdrawal.

If I have not been required to supply documentation of my hardship event and hardship amount to my

Plan Administrator in connection with my hardship withdrawal request, I understand and agree that I

am required to maintain records of such documentation of the hardship event and amount, and I will

provide such documentation to my Plan Administrator or its designee upon request. Consult your tax advisor for additional details on tax consequences.

SIGNATURE

_____________________ Participant Signature Date

Do not submit this form to MassMutual.

.

Documentation Guidelines - These guidelines are subject to any differing or additional requirements as may be determined under the plan and/or by the

plan sponsor.

Reason for Withdrawal Documentation Guidelines

Expenses for Medical Care for myself, my spouse, my

children, my other dependent(s) or my primary

beneficiary (as permitted under the plan).

Services provided

Bill dated within the last 60 days with amount due

List of services provided and insurance payments listed on bill OR Explanation of

Benefits

Services not provided yet

Treatment plan dated in the last 60 days

List of services to be provided with costs and insurance payments to be

applied, if no insurance it must state there is no insurance coverage

Must indicate "Pre-payment is required" on document

Purchase of My Principal Residence

(excluding mortgage payments).

Financed purchase

Loan estimate dated within 60 days

Property Address listed

Cash purchase

Executed Sales Contract or Purchase and Sales Agreement, dated within last 60 days

including:

Property address

Purchase price

Closing date

Land Purchase to build primary residence

Executed contract, dated within last 60 days

Construction Loan copy

Commitment Letter from lender

Note: supporting documentation must be received and approved prior to closing date

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Prevention of Eviction from or Foreclosure of my

principal residence.

Eviction

Eviction notice dated within the last 60 days including:

Property address

Date it must be paid by (must be a future date at least 5 days in the future

from the date request is submitted to MassMutual)

Amount due

Language stating you can stay if you pay the amount requested

Lease agreement if individual landlord, if no lease eviction notice must state

monthly rental amount and that rent is paid month to month

Foreclosure

Foreclosure notice/default letter dated within the last 60 days including:

Property address

Date it must be paid by (must be a future date)

Amount due

Note: Cannot be the monthly mortgage statement

Tuition and Related Education Fees including room

and board expenses for the next 12 months for post-

secondary education for myself, my spouse, my

children, my other dependent(s) or my primary

beneficiary (as permitted under the plan)..

Tuition expenses

Bill with the school name dated within the last 60 days including:

Student's name

Net amount due

Charges and Credits including financial aid (cannot be simply the cost of the

school but your personal bill showing the net amount due)

Term charges are for

Books

Online shopping cart print out of "voided" receipt showing the cost of books or

supplies required

Note: We cannot reimburse for purchases already made nor can we approve for student loans Expenses for the Repair of Damage on my principal

residence that would qualify for the casualty

deduction under §IRC 165.

Estimate of cost listing repairs dated within the last 60 days.

Homeowner's insurance coverage or denial, if no homeowners insurance, the estimate must state

exact cause of damage and that no insurance money will be accepted toward payment.

Payment of Burial or Funeral Expenses

for my deceased parent, spouse, children, dependents

or primary beneficiary (as permitted under the plan).

An itemized/detailed bill dated within the last 60 days from a funeral home, mortuary, crematorium

and or religious establishment including:

Charges

Payments/Credits

Note: Flowers and Family vehicles, such as limousines, are not approvable

Expenses and losses as a result of a federally

declared disaster (to the extent permitted by your

plan). Expenses and losses (including loss of income)

incurred by the employee in connection with certain

disasters declared by the Federal Emergency

Management Agency (FEMA), provided that the

employee's principal residence or principal place of

employment at the time of the disaster was located in

an area designated by FEMA for individual assistance

with respect to the disaster (to the extent permitted by

your plan).

An itemized description identifying the expense(s) or listing of unpaid invoice evidencing the expense

(s), itemization of the costs, total amount due and insurance payment amount(if applicable).

An itemized receipt identifying the expense(s) (dated within 60 days as of the date of the request) or

an unpaid invoice evidencing the expense(s), name of billing entity, itemization of the costs, total

amount due (dated within 60 days as of the date of the request).

Additional information as may be required by your plan administrator.

(For loss of income) Participant's last three payroll paystubs.

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