QDRO Processing Form Part 1 – QDRO Assignment …

QDRO

f6789 COMPLETE ALL PAGES MassMutual, PO Box 219062, Kansas City MO 64121-9062

For Overnight Mail: MassMutual, 430 W 7th St, Kansas City MO 64105 Copyright © 2019. All rights reserved. Massachusetts Mutual Life Insurance Company (MassMutual), Springfield, MA 01111.

QDRO Processing Form Part 1 – QDRO Assignment Authorization

1. QDRO ELECTION Account Number _________________ Sponsor Name _______________________________________________________

New QDRO Set-Up and Payout – Complete Parts 1 and 2 of this form. Plan must allow for immediate payout to select this option. If part 2 of the form is not included, only the setup of the QDRO will be completed and funds will be invested in the Alternate Payee’s account to mirror the Participant’s elections.

New QDRO Set-Up – Complete Part 1 of this form. Existing QDRO Payout – If you previously submitted this form to set up a separate account for Alternate Payee, and the account can

now be paid out, complete Part 2 of this form only.

2. PARTICIPANT INFORMATION

Social Security No. __________________ Participant’s Name _________________________________________________ first middle last

Participant's Address _________________________________________________________________________________ street _________________________________________________________________________________ city state zip

3. ALTERNATE PAYEE INFORMATION

Alternate Payee Relationship: Former Spouse Non-spouse [Complete and attach a separate form for each Alternate Payee.] Alternate Payee's Name ______________________________________________________________________________ first middle last Social Security No: _____________________ Date of Birth (mm/dd/yyyy) ____________

Alternate Payee’s ___________________________________________________________________________________ Address street _________________________________________________________________________________ city state zip Legal State of Residence _________________________________ Phone Number _______________________ If the Legal State of Residence is not provided, MassMutual will use the state provided in the Alternate Payee’s Address for state tax purposes.

4. ALTERNATE PAYEE BENEFIT INFORMATION - To be completed by the Plan Administrator Note: Do not send the Court Order to MassMutual.

I, the Plan Administrator, reviewed the domestic relations order for the Participant in which a portion of the account balance is awarded to the Alternate Payee, and I determined the order constitutes a Qualified Domestic Relations Order pursuant to Internal Revenue Code Sections 401(a)(13) and 414(p). Assignment Amount: $ ____________ or ____ % from the Participant’s account balance as of the Valuation Date chosen below:

Note: Contribution sources and investments will be transferred on a pro-rata basis (i.e., the same ratio of contributions/investments will be transferred out of the Participant’s account and into the Alternate Payee’s account). We will mirror the Participant’s investments unless we are provided an “In Good Order” enrollment form specifying the Alternate Payee’s investment allocations to be applied to the Alternate Payee’s account.

Valuation Date (select one): Specified Effective date (mm/dd/yyyy) ___________ Date QDRO is processed by MassMutual.

Earnings (only applies if a Specified Effective date is chosen - select one) - From the effective date until the date the money is moved to

the alternate payee’s separate account, investment gain or loss should: Be added to the amount of benefit as of the effective date entered above by (select one – If no calculation is elected, Earnings will be based on the Amount of the Account’s Rate of Return):

The Amount of Benefit’s Rate of Return (A calculated overall rate of return of the account during the period between the effective date of the QDRO and the actual division of the account pursuant to the QDRO, which is based on the beginning and ending account balance and is time weighted to reflect the duration of the assets within the account attributable to transactions during such period, including contributions, withdrawals and loans, if any. This will be used as the default if no other election is made).

Fixed rate of interest of ______% (do not annualize) Other: ______________ (please specify earnings dollar amount in accordance with the QDRO).

Not be added to the amount of benefit.



Loan Balances: The vested account balance for this determination: includes excludes outstanding loan balances.

Vesting (if applicable): For determining the assignment amount, we will use the: vested account balance or total account balance.

If the participant is partially vested as of the QDRO Valuation date and the assignment is based upon the participant’s vested account balance, please provide the vesting information below:

Vesting: Employer Match

%

Vesting: Employer Profit Sharing

%

Vesting: Other (Specify)

%

Note: If no Vesting election is made above, MassMutual will default to total account balance.

Does the Effective date of this QDRO precede MassMutual receiving the Participant’s assets? No Yes (if yes, please complete Assets from Prior Record Keeper section below).

Assets from Prior Record Keeper (if applicable): If MassMutual did not record keep your Plan as of the Valuation Date, you will need to provide us with additional information. Please provide the amount (assignment plus earnings or gain/loss) that the Alternate Payee would have received had the assignment been processed on the date the assets were transferred to MassMutual:

$________________ $________________ assignment amount earnings

Please note: you must specify an earnings dollar amount in accordance with the Court Order.

5. PLAN ADMINISTRATOR CERTIFICATION AND AUTHORIZATION I certify that I, as the Plan's authorized representative, and not MassMutual, have made the fiduciary determination as to the qualification of the Participant's Domestic Relations Order and any related determination. I authorize MassMutual to transfer the Alternate Payee’s QDRO assignment from the Participant’s account into an account established for the Alternate Payee pursuant to this form’s instructions and information on record at MassMutual. I certify as Fiduciary of the Plan that the Domestic Relations Order meets all of the qualification requirements of a qualified domestic relations order (“QDRO”) within the meaning of Internal Revenue Code section 414(p), REA and ERISA, which has been issued by a court of competent jurisdiction and that such order assigns the amounts indicated in this form from the Participant’s account under the Plan to the Alternate Payee in accordance with the terms of the Plan. I further authorize MassMutual to remove the hold placed on the Participant’s account (if applicable) in accordance with the Plan’s QDRO procedures. I further certify that the information and instructions contained in this form are true and accurate and consistent with the terms of the Plan to the best of my knowledge. I understand that if there are insufficient assets in the Participant’s vested account balance to satisfy the Alternate Payee’s assignment as directed by the QDRO, this QDRO Processing Form, Part 1 - QDRO Assignment Authorization (and, if applicable, Part 2 - QDRO Benefit Payment Request) will be considered as “Not In Good Order” by MassMutual and will not be processed as it may no longer meet the QDRO qualification rules. MassMutual will notify me accordingly and recommends that, in such event, I discuss this matter further with the Plan’s own legal counsel. On behalf of the Plan and the Plan Sponsor, the Authorized Plan representative certifies that: (i) MassMutual has not provided legal or tax advice to the Plan Sponsor in connection with or with respect to the transaction(s) reflected on this form; (ii) any materials or information provided by MassMutual to the Plan Sponsor, including the QDRO Informational Kit, are for educational purposes only and are not specific to the transaction(s) reflected on this form or any other similar transactions; (iii) the Plan Sponsor has consulted with its own tax or legal advisors , as necessary, before authorizing the transaction(s) reflected on this form and has not solely relied on the general educational or other materials provided by MassMutual; (iv) the Plan Sponsor agrees that MassMutual shall be fully protected in relying on these instructions and shall have no duty of further inquiry. _______________________________________________ _______/_______/_______ Authorized Plan Administrator’s Signature Date _______________________________________________ Authorized Plan Administrator’s Name (please print)

QDRO



QDRO Processing Form

Part 2 – QDRO Benefit Payment Request 1. PLAN INFORMATION - Required

Account Number __________________ Sponsor Name __________________________________________________________

Plan Name ______________________________________________________________________________

2. PARTICIPANT INFORMATION - Required

Social Security No. ___________________ Participant’s Name ________________________________________________ first middle last Participant's Address _________________________________________________________________________________ street _________________________________________________________________________________ city state zip

3. ALTERNATE PAYEE INFORMATION - Required

Alternate Payee Relationship: Former Spouse Non-spouse [Complete and attach a separate form for each Alternate Payee.] Alternate Payee's Name ______________________________________________________________________________ first middle last Social Security No: _____________________ Date of Birth (mm/dd/yyyy) ____________

Alternate Payee’s ___________________________________________________________________________________ Address street _________________________________________________________________________________ city state zip Legal State of Residence _________________________________ Phone Number _______________________ If the Legal State of Residence is not provided, MassMutual will use the state provided in the Alternate Payee’s Address for state tax purposes.

4. BENEFIT PAYOUT (Select One) – To be completed by the Alternate Payee

One-Sum Cash Payment of the benefit as a direct payment to me. (Distribution will be processed for “All” if no Amount is specified below) All (my total vested account balance) Amount of (a partial cash payment): $ _____________________________ Pay the remaining account balance as otherwise elected on this form. Leave the remaining account balance in the Plan. Only available if permitted by the Plan and if your remaining account balance

exceeds the Plan’s minimum cashout amount (commonly $5,000). The Plan may exclude rollover contributions in determining account balance. [Note: It is your responsibility to request a distribution by the required deadline: April 1st of the year following the year you attain normal retirement age, attain age 70½, or retire after attaining age 70½, depending on Plan provisions and other factors. More information can be provided upon your request.]

Installment Payments (if permitted by the Plan): Installment Process Date: Select a date for payments to begin. Select a day from 1-28. The 1st day of the month is the default if no election is made or the day chosen is not between 1-28. When selecting your date, this is the day your payment will be processed.

Effective: Month (MM) ____ Day (DD) ____ Year (YYYY) ______

Note: If the date you select falls after the date MassMutual processes this form, your 1st installment will be paid on the next available month of the date you selected.

In order to make any changes to this election, you will need to contact MassMutual.

Payments are to be made: Monthly Quarterly Semi-Annually Annually

For a Fixed Period of _______ years (not to exceed life expectancy) For a Fixed Amount: Each payment should be a gross amount of: $_____________. I understand that any income tax

withholding will be deducted from this amount. [Note: These payment amounts may need to be adjusted at age 70½ to meet IRS minimum distribution rules.]



For the maximum period allowed by law: [Note: Changes to life expectancy and calculation method may be limited or not allowable based on the Plan document.] Life Expectancy: my life only my and my beneficiary’s lives (beneficiary’s birth date ___________) Calculation Method: term certain (at time of first payment) recalculation (annually) mm/dd/yyyy.

Spousal QDRO Only: A Direct Rollover of:

All or Amount: $_____________ To: my IRA my employer's eligible plan. No, do not include After Tax Amount (if applicable) Yes, Include After Tax Amount (if applicable). Make sure the rollover plan accepts after tax dollars. If no election is made, a check will be issued payable to you for the after tax amount. Name of financial institution/name of employer’s plan to whom the rollover check should be issued: ___________________________________________________________________________ [Note: If a portion of the benefit is rolled over, the remainder is paid as a one-sum cash payment to the alternate payee.]

Spousal QDRO Only: Conversion to my Roth IRA: Payment (except required minimum distributions) to my Roth IRA.

Name of financial institution to whom the rollover check should be issued: ___________________________________________________________________________ [Note: If a portion of the benefit is rolled over, the remainder is paid as a one-sum cash payment to the alternate payee.]

Joint and Survivor Annuity (if permitted by the Plan): A survivor annuity purchased from

Massachusetts Mutual Life Insurance Company. After my death, 100% 75% 66⅔% 50% of the annuity payments should continue to my Joint Annuitant. The annuity election cannot be revoked once payments commence. Joint Annuitant's Name ___________________________________ Birth Date __________________________ Relationship ____________________________________________ Social Security No.___________________ Payments commencing: immediately at participants’ earliest retirement age (deferred)

Annuity – Other than Joint and Survivor (if permitted by the Plan): An annuity contract purchased from Massachusetts Mutual Life

Insurance Company. The beneficiaries I previously designated continue under the Stipulated or Full Cash Refund Annuities. The annuity election cannot be revoked once payments commence.

Primary Beneficiary's Social Security No.______________ (Attach separate sheet with numbers if more than one beneficiary.) Life Annuity Life Annuity with 120 Stipulated Payments Full Cash Refund Annuity

Payments commencing: immediately at participants’ earliest retirement age (deferred)

5. SOURCE OF PAYMENT FOR PARTIAL WITHDRAWALS

If you requested a partial withdrawal from your vested account, your payment will be processed using MassMutual’s normal default withdrawal hierarchy unless Special Instructions are provided below. Special Instructions: ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ If you have elected an installment payment and are requesting it from a specific fund(s)/source(s) in this section, please note that you have two options when any specific fund(s)/source(s) vested balance falls below the requested installment amount:

Your installment payments will continue using MassMutual’s normal default withdrawal hierarchy

Your installment payments will stop, and new instructions will need to be provided If you do not check one of these two options, your installment payments will continue using MassMutual’s normal default withdrawal hierarchy.

6. INCOME TAX WITHHOLDING Complete this section if benefit is immediately payable.

FEDERAL INCOME TAX WITHHOLDING ELECTION (Participant completes)

Distributions of pre-tax contributions plus earnings on all contributions are subject to federal income tax. Federal income tax law requires that 20% of the taxable amount of the distributions be withheld, unless the payment is directly rolled over to an eligible plan or an IRA. Installment and annuity payments payable over life expectancy or 10 years or more are not eligible to be rolled over, and you have the choice to have



federal income tax withheld (if no election is made, MassMutual will withhold federal income tax). Please have the alternate payee read the Special Tax Notice. The alternate payee, and the participant in the event of a non-spousal payee, should contact a tax advisor or IRS with any questions concerning tax withholding.

Note: If this section is completed incorrectly based on Federal or State requirements, only mandatory Federal and State tax withholding (if applicable) will be withheld from your distribution.

Spousal Payee: (Completed by Alternate Payee) Withholding does not apply as the entire taxable amount is being directly rolled over.

Deduct the 20% mandatory federal income tax withholding from the taxable portion of my one-sum cash payment or installment payments for under 10 years.

Deduct the 20% mandatory federal income tax withholding from the taxable portion of my one-sum cash payment or installment payments for under 10 years and withhold an additional amount of $____________.

Deduct federal income tax from my installment/annuity payments of 10 years or more or based on life expectancy according to my elections below (refer to IRS instructions for Form W-4P for more information):

a. Single Married Married, but withhold at the higher single rate b. Number of allowances ________ c. I want the following additional amount withheld from each payment: $________________________

Non-spouse Payee: The Participant is responsible for Federal income tax for this QDRO distribution. No withholding will be taken and tax reporting will be issued under the Participant’s social security number. STATE INCOME TAX WITHHOLDING (Participant completes)

You may skip this Section if you reside in a state with no income tax or withholding requirement on retirement income.

The taxable portion of your payment may be subject to state income tax withholding requirements. While MassMutual will withhold based on your state's income tax rules and your election, if applicable, you are responsible for ensuring you satisfy your individual state income tax liability. If you make an election that is not in compliance with your state's income tax withholding rules, then MassMutual will default to your state's income tax withholding requirements.

State Income Tax Withholding rules are subject to change at any time. For current state specific tax information pertaining to your resident state, you should contact your tax advisor or your state income tax department. Also note, state tax rules may apply differently depending on your type of distribution (i.e., lump sum, periodic, non-periodic, etc.). In addition, some states allow for an exclusion from income distributions from certain retirement plans - to confirm whether you may qualify to exclude all or a portion of your distribution from income for state taxation purposes, you should consult your plan sponsor or state income tax department.

If your state's income taxes are determined based on wage tables, MassMutual is unable to calculate a net amount, you will need to ensure that you have grossed up accordingly. Your request may be delayed if a net amount is requested.

If you do not see your state listed below, it is a result of your state not permitting state income tax withholding.

Any tax information included in this written or electronic communication was not intended or written to be used, and it cannot be used by the taxpayer, for the purpose of avoiding any penalties that may be imposed on the taxpayer by any governmental taxing authority or agency.

Your state income tax withholding options are:

AR, DE, IA, KS, MD, MA, NC, NE, OK, VT, VA

These states require mandatory state income tax withholding on taxable distributions. MassMutual is required to withhold state income taxes based on state law. You may not elect out of state income tax withholding.

Requests for Required Minimum Distributions (RMDs) and installment payment programs over a period of 10 years or more are not eligible to be rolled over. If you choose to opt out of federal income tax withholding, MassMutual will automatically opt you out of state income tax withholding. If you did not opt out of federal income tax withholding, then MassMutual will withhold based on state law.

I elect to withhold an amount of $_________ (whole dollar amount) or ____%



CA, ME, OR, DC These states require mandatory state income tax withholding. MassMutual is required to withhold state income taxes based on state law unless you elect out of withholding. I elect no state income tax withholding.

Note: The District of Columbia only requires mandatory withholding on a “lump sum” distribution that brings your account balance to zero. If you are requesting a “lump sum” distribution, then you may not opt out of withholding.

AL, AZ, CO, ID, IL, IN, KY, LA, MO, MS, MT, NJ, NM, NY, ND, OH, PA, RI, WV, WI

These states permit voluntary state income tax withholding. You may voluntarily elect state income tax withholding by providing a dollar amount or percentage below. If no election is made for these voluntary states identified, then MassMutual will not apply any withholding.

I voluntarily elect to withhold an amount of $_________ (whole dollar amount) or ____%. Note:

IL only permits voluntary state income tax withholding on periodic payments. Lump sum distributions do not allow for state income tax withholding. If a tax election is requested on a lump sum distribution, MassMutual will not apply any withholding.

AZ only permits voluntary state income tax withholding on periodic payments where you may only elect one of the following percentages 0.8%, 1.3%, 1.8%, 2.7%, 3.6%, 4.2%, 5.1%. If any other percentage or dollar amount is requested above, MassMutual will not withhold. If a tax election is requested on a lump sum distribution, MassMutual will not apply any withholding. If additional amount is requested for periodic payments, please complete section below.

GA, MN, SC, UT

These states permit voluntary state income tax withholding. You may voluntarily elect state income tax withholding by selecting the box below. If no election is made for these voluntary states identified, then MassMutual will not apply any withholding. Please note only Gross Distribution requests are permitted when applying state income tax withholding.

Withhold based on my state's tax table formula, if applicable (MassMutual will apply the default tax allowance.)

CT, MI These states require mandatory state income tax withholding. MassMutual is required to withhold state income taxes based on state law unless you provide an alternate dollar amount or percentage withholding instruction below, along with completing your state specific W-4P withholding certificate and submitting it with this form. If a W-4P is not provided, MassMutual will default to your state’s mandatory max withholding amount. Note: CT residents, W-4P is only allowed for partial distributions.

I elect to withhold an amount of $_________ (whole dollar amount) or ____% Additional State Income Tax Withholding

I elect to have an additional ____% or $_________ (whole dollar amount) if state income tax withheld from my payments. This withholding will be in ADDITION to any withholding selected above.

7. DELIVERY INSTRUCTIONS (complete if applicable) Direct deposit to a bank account of which I am an authorized account holder.

This option is NOT available for Rollovers.

To elect Direct Deposit, you must select either Checking or Savings and you must provide a voided check or a bank specification sheet from your bank for validation.

To help protect our customers’ assets, MassMutual may independently validate bank and customer account information before processing Direct Deposit/EFT. If we are unable to independently validate the bank and customer account information or sufficient documentation to support the Direct Deposit/EFT is not provided, we will mail a check to the address of record. It should be noted that we are not always able to independently validate credit unions or smaller banks. If the account cannot be validated, a check will be mailed even if a voided check or financial instrument is submitted with distribution request.



Checking Savings

___________________________________ __________________________________________ _______________________________________ Bank Name Bank ABA/Routing (9 digits) Bank Account No.

Please note that we can only send funds via direct deposit to banks with a valid U.S. routing number.

I understand that if I do not fully complete this section or the bank account information I have provided is invalid, a check will be mailed. I understand that a reprocessing fee may be charged to my account if the direct deposit is declined by my financial institution. Subsequent withdrawals will be processed in the same manner (up to 180 days from the date of the original distribution) unless I notify MassMutual in writing to distribute the money differently. I also authorize MassMutual to initiate a debit to my account for any overpayment or payments made in error. Send my payment by check to the address listed in Section 3 of this form.

8. SIGNATURES

I understand that I have the right to a 30-day election period. I further acknowledge that if I sign this form before the completion of the election period, I am waiving the 30-day election period by making an affirmative election on this distribution form. I also understand there may be a charge for each Single Sum benefit payment or rollover issued directly to or on behalf of (in the event of a Trustee to Trustee transfer of eligible rollover distribution) a Participant, beneficiary or alternate payee. If I am selecting installments or an annuity, there will be a one-time installment or annuity set-up fee deducted from my account. For more information about fees, visit the retirement web portal at www.RetireSmart.com. Select the Current Retirement Statement at the top of the Statements/Required Disclosures page. I understand that if all of the items are not completed on this form, payments will be delayed. If electing direct deposit, by signing below I certify that I am an account holder on the bank account listed above.

_______________________________________________ _______/_______/_______ Alternate Payee Date

As authorized representative of the Plan, I hereby direct MassMutual to withdraw from the alternate payee's account the amount necessary to pay the distribution in the manner indicated in this form in accordance with the terms of the Plan and alternate payee's elections. I have verified the Participant and Alternate Payee Information in Parts 2 and 3 and certify that it is true and accurate to the best of my knowledge.

_______________________________________________ _______/_______/_______ Plan Administrator Date

RS-38939-01

Documents

QDRO Processing Form Part 1 – QDRO Assignment …