Dear Participant: RE: Request for Hardship Distribution under the

Transcription

12/02/2013
[Date]
[Participant Name
Participant Address1
Participant City ST Zip]
Dear Participant:
RE: Request for Hardship Distribution under the Plan (“Request for Distribution”)
Constructors Annuity and 401(k) Retirement Plan
[Account
Plan Name]
60041-1-1 Number –Elevator
MassMutual has received your request for a hardship distribution from your retirement
account. Please complete the enclosed Application for Hardship Withdrawal, provide
supporting documentation for your request as outlined in the attached Appendix IV, and
return it to:
MassMutual Retirement Services
PO Box 219062
Kansas City MO 64121-9062
For Overnight Mail:
430 W 7th St
Kansas City MO 64105
To expedite your request, please fax documentation to (816) 701-3923.
In applying for a hardship distribution, there are a few things to keep in mind:
•
If your hardship application is approved, you will not be permitted to make any
contributions to your plan for six months from the time of the distribution.
•
In order to receive a hardship distribution, you must provide documentation to
support the reason for your need. A list of the appropriate forms of
documentation is included with the Application for Hardship Withdrawal. If the
supportable documentation that is provided is less than the amount requested, the
amount of the distribution will be processed based on the approved
documentation.
•
As part of your application process, you must certify that you have obtained all
nontaxable loans from the Plan (if applicable) and all other plans maintained by
your employer that are reasonably available to you. By completing the attached
Application for Hardship Withdrawal and returning it for processing, you are
certifying that there are no other loans reasonably available to you through your
employer. A loan is considered “reasonably available” as long as it does not have
the effect of increasing your need. Consider the following examples in which
receiving a loan would increase the need:
o
o
Taking out a loan in order to purchase a principal residence would disqualify
you from obtaining other financing.
The amount of the loan repayments would cause you to default on the loan.
If you feel that loans are reasonably available to you, or if you have any questions
regarding your application for a hardship distribution, please contact the Participant
Information Center at (800) 743-5274, 8:00 AM EST to 8:00 PM EST. In addition, you
can contact the Participant Information Center by email through the RetireSMARTSM
participant website. Log into RetireSMARTSM and then, in the upper right corner, click
on “Contact Us”; this will send an email directly to the Participant Information Center.
Sincerely,
MassMutual
RS-07478-01
08/18/2008
MassMutual Financial Group is the fleet name for Massachusetts Mutual Life Insurance Company (MassMutual) [of which Retirement
Services is a division] and affiliates
Documentation Required For Hardship Approvals
The documentation/information below is needed to complete, approve and process your hardship withdrawal request. Note: All requests require
proper documentation, and can not be approved or processed unless it is provided. If MassMutual requests additional information and the required
documentation is not received, the hardship request will be closed and you may be charged for the review. For additional details please refer to the
Explanation of Hardship and Supporting Documentation that was enclosed in your package.
Please pay close attention to the required information that must be included with your specific hardship submission, to ensure your
request can be completed in a timely manner.
Medical Expenses
A copy of the bill for services, current within 60 days, that shows the outstanding balance due.
If the medical procedure has not yet occurred, please provide:
9 A letter from the physician stating that pre-payment is necessary AND
9 A letter from the insurance provider with the amount to be covered by insurance-if no insurance the estimate/treatment plan must state no
insurance coverage.
An Explanation of Benefits (EOB) (from your insurance provider) for each bill, showing what services/procedures were provided, what portion
of the expense was covered by insurance OR documentation indicating that the expense is not reimbursable from insurance
Documentation for each bill, explaining what services were provided AND the service dates. (Commonly, these are found on the Explanation
of Benefits.) This is needed in place of an EOB. If the bill lists the details of the services/procedures provided, an EOB is not needed.
Prevention of Eviction or Foreclosure
A copy of the Notice of Eviction. The Notice of Eviction by the landlord, apartment complex, or court must state:
9 The amount due to prevent eviction.
9 A future date for eviction (at least 5 business days in the future from the date you submit to MassMutual) that states that you “will” be
evicted (not “may”), if the amount due is not made current.
9 If you pay the amount stated, you will be allowed to stay at the property.
9 A signature of the landlord must be present on the Notice.
o If Notice of Eviction is issued by a landlord or court, you must also provide the Lease Agreement for the property.
9 The property address.
A copy of the Notice of Foreclosure. The foreclosure notice must be issued by a bank, or a mortgage company and state:
9 The amount due to bring the mortgage current
9 Foreclosure proceedings will commence if the amounts owed are not paid by a future date.
9 The property address.
Purchase of Primary Residence
A good faith estimate (GFE) issued by a bank or mortgage company that contains closing costs, date of closing, and the address of the
property. If the requested amount is more than the settlement charges on the GFE, a sales contract/agreement is required.
For a land purchase only: Evidence from the contractor of the immediate building of the primary residence.
For the construction of a primary residence: An executed contract between the builder and yourself (which may include dates and amounts of
periodic disbursements to the builder), a copy of the construction loan, and a commitment letter from a bank or mortgage company.
Tuition and Related Education Fees
A current tuition bill indicating the name of the student and the semester or term, with the institution name present on the bill.
The bill must indicate the current outstanding amount due for the student, not simply list the cost of attending the institution.
The tuition must be for accredited secondary education resulting in a degree or certificate.
Funeral Expenses
Need a current itemized bill for burial and/or funeral expenses incurred that indicates the name of the funeral home, mortuary, crematorium,
monument company and/or religious establishment. Bill for funeral expenses must indicate the name of the spouse, child, parent or other
dependent on whose behalf the services were furnished.
Expenses for Repair of Damage on a Principal Residence (Internal Revenue Code Section 165 Casualty)
Must be as a result of a loss that arises from fire, storm, or other casualty, or from theft.
A statement from the insurance carrier evidencing a denial of coverage for the cost of repairs.
For prepayment of costs; need an estimate from the contractor.
For building a principal residence destroyed by a casualty; an executed contract between you and the contractor.
In addition to obtaining the proper documentation located in the above checklist, please review your Hardship Withdrawal
Request to ensure that you have:
9 signed the form
9 indicated the amount of withdrawal request (net or gross)
9 completed the withholding section
9 returned all pages of the distribution form.
RS-18073-01
This Page Is Intentionally Left Blank.
APPLICATION FOR HARDSHIP WITHDRAWAL
To be Completed by the Participant:
Participant's Name
Social Security No.
___________________ __________________
______________________
first
last
middle
_____________________
Address ___________________________________________________________________________
street
___________________________________________________________________________
city
state
zip
Legal State of Residence _________________________________
If the Legal State of Residence is not provided, MassMutual will use the state provided in the Mailing Address for state tax purposes.
Check if Mailing Address or Legal State of Residence has changed.
Marital Status:
Married
Not Married or Legally Separated
If there is a question about my request, I prefer to be contacted by:
⁭ E-mail Address: ________________________________________
⁭ Phone Number #: _______________________________________
To be Completed by MassMutual:
60041-1-1
Account Number _____________________
Trustees, ECA & 401(k)
Sponsor Name ______________________________________________________________________
Elevator Constructors Annuity and 401(k) Retirement Plan
Plan Name ______________________________________________________________________________
HARDSHIP REQUEST
1.
I request a withdrawal due to hardship in the following amount:
Gross Amount: Withdraw $__________ from my vested account balance. I understand that any
income tax withholding will be deducted from this amount.
Net Amount: Withdraw $__________ from my vested account balance plus withdraw any income
tax withholding.
I understand that:
1) My distribution will be limited to the amount available or the amount that can be approved based on
the documentation provided, and
2) If I do not elect a Gross or Net amount, I will receive the distribution as a Net amount, and
3) If I do not specify an amount, the distribution will be processed for the lesser of the approved amount
or the amount available.
2.
I certify that the amount of hardship in item (1) above is for the following reason(s):
Expenses for Medical Care for myself, my spouse, my children, my other dependent(s), or, if
permitted by the Plan, my primary beneficiary.
Purchase of My Principal 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 children, my other dependent(s) or, if
permitted by the Plan, my primary beneficiary.
Prevention of Eviction from or Foreclosure on the mortgage on my principal residence. I certify
that I am currently living at the address stated in the submitted hardship documentation.
Expenses for the Repair of Damage on my principal 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,
if permitted by the Plan, my primary beneficiary.
60041-1-1
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MassMutual Retirement Services (MMRS) is a division of Massachusetts Mutual Life Insurance Company (MassMutual) and affiliates.
To receive the hardship withdrawal requested above, I certify that the following requirements have been or
will be satisfied:
1. The withdrawal amount requested will not be in excess of the amount of the financial need.
2. I previously have obtained all distributions and nontaxable loans from this Plan and all other plans
maintained by my employer that are reasonably available to me (i.e., the loan(s) will not increase my
level of need). A loan is considered “reasonably available” so long as it does not have the effect of
increasing your need, such as
• Taking out a loan in order to purchase a principal residence that would disqualify you from
obtaining other financing; or
• The amount of the loan repayments would cause you to default on the loan.
3. I will not be able to make any contributions to any qualified or non-qualified plan maintained by my
employer, including a cash or deferred arrangement that is part of a cafeteria plan within the meaning
of section 125 (but excluding a health or welfare benefit plan) for at least 6 months after I receive the
hardship withdrawal; and
Failure to produce the substantiating documentation will mean denial of my hardship request. (For a list
of approved forms of documentation, please see the “Permissible Hardship Expenses and Supporting
Documentation” included with this application.).
INCOME TAX WITHHOLDING
You may elect to have federal and state taxes withheld from your hardship distribution. The amount that you
elect to withdraw may not exceed the amount of federal and state taxes that would apply as a result of the
hardship distribution. If you do not make any tax withholding election for Federal or State taxes related to your
hardship distribution, 10% will automatically be withheld for Federal taxes and the amount of State taxes that
will be withheld will be based on the applicable withholding requirements of your State.
FEDERAL WITHHOLDING: Distributions of pre-tax contributions plus earnings on all contributions are subject to
federal income tax. Hardship withdrawals are not eligible to be rolled over, and you have the option whether or not to
have federal income tax withheld. If you elect to have withholding, 10% will automatically be withheld for federal
income tax.
I elect to have federal income tax:
withheld
not withheld.
In addition to this federal income tax withholding, I want an additional amount withheld of $_________.
Please read the Special Tax Notice(s). Contact your tax advisor or the IRS if you have any questions concerning
tax withholding.
STATE WITHHOLDING: Contact your tax advisor or your state’s tax department if you have any questions
concerning state tax withholding. Refer to the State Tax Information document for important information regarding
State Withholding in your Legal State of Residence. If you make an election that is not in compliance with your
state’s regulations, MassMutual will default to your state’s requirements.
No State Tax Withholding Election
I have read the State Tax Information document and I elect to have no state income tax withheld from my
payment(s).
Voluntary State Income Tax Withholding
I have read the State Tax Information document and I elect to have the following voluntary state income tax
withheld from my payment(s) (choose one):
____%
$________ (whole dollar amount)
___ based on my state's tax table formula, if applicable (MassMutual will apply the default tax allowance)
Note: MassMutual will not withhold more than your State’s personal income tax rate.
METHOD OF PAYMENT

Direct deposit to a bank account of which I am an account holder - Deposited within 3 business days from date of
processing.
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 copy of a preprinted, account-specific deposit slip or a bank specification sheet from your bank for validation.
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.
60041-1-1
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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 payment by check - Allow up to 10 business days for postal service delivery.
SIGNATURE
I understand there may be a charge deducted from my account for each distribution processed for the hardship
review service, whether my request is approved or not. If all required items are not completed on this form along
with proper supporting documentation, payment will be delayed. If electing direct deposit, by signing below I
certify that I am an account holder on the bank account listed above.
By signing this form, I certify that the information I have provided is accurate, to the best of my knowledge. I
also certify that I have read and understand the Explanation of Hardship and Supporting Documentation
document. I also certify that I have obtained, and will provide upon request by MassMutual, the documentation
necessary to support my hardship withdrawal request, including a completed Waiver of Preretirement Survivor
Annuity form if the Plan requires spousal consent and I am married.
_____________________
Participant Signature
Date
Please return this form to:
PO Box 219062
Kansas City MO 64121-9062
OR
For Overnight Mail:
430 W 7th St
Kansas City MO 64105
OR
Fax to:
(816) 701-3923, Attn: RS CSO Processing
OR
Email to:
60041-1-1
[email protected]
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Appendix IV
Explanation of Hardship and Supporting Documentation
Definition of “Dependent,” as defined by Sections 152(c) and 152(d) of the Internal
Revenue Code shall mean with respect to a participant:
A qualifying child: An individual who (i) is a child of the participant (or a
descendent of such a child), a brother, sister, stepbrother, or stepsister of the
participant or any such descendent of any such relative; (ii) who has not attained
age 19 as of the close of the calendar year in which the taxable year of the
participant (taxpayer) begins or is a student who has not attained age 24 as of the
close of such calendar year. The age requirement in (ii) shall be treated as met in the
case of a dependent who is permanently and totally disabled at any time during such
calendar year.
A qualifying relative: An individual (i) who is a child (or a descendant of a child),
brother, sister, stepbrother, stepsister, father, mother (or ancestor of father or
mother), stepfather, stepmother, son or daughter of a brother or sister of the
participant, brother or sister of the father or mother of the taxpayer, son-in-law,
daughter-in-law, father-in-law, mother-in-law, brother-in-law, sister-in-law, or an
individual who, for the taxable year of the participant, has the same principal place
of the abode as the participant and is a member of the participant's household; (ii)
with respect to whom the taxpayer provides over one-half of the individual's
support for the calendar year taxable year begins; and (iii) who is not a qualifying
child of such participant or of any other taxpayer for any taxable year beginning in
the calendar year in which such taxable year begins.
I.
Medical Care
A. You may receive a hardship distribution for amounts not covered by insurance for the
following medical care expenses permitted under section 213(d) of the Internal
Revenue Code:
• Operations/treatment affecting any part of the body (not for surgery solely for
cosmetic reasons)
• Obstetrical expenses
• Invitro fertilization
• Vasectomy
• Therapy
• X-ray treatments
• Hospital services
• Nursing services
• Medical services
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Laboratory services
Surgical services
Laparoscopic surgery (if deemed medically necessary by a doctor)
Dental services
Diagnostic services
Gastric by-pass surgery (if medically necessary as evidenced by a doctor)
Healing services
Prescribed drugs. Forecasting is allowed based on quantity of specified refills, up
to six months. Cost of medication and number of refills must be provided.
Artificial teeth
Artificial limbs
Ambulance hire
Lodging (while away from home primarily for and essential to medical care,
limited to $50 per night)
Transportation for and essential to receipt of medical care
Hearing aids (cost of hearing aid and batteries to operate device). Forecasting is
allowed, for a six month period, in cases where the device is being rented.
Reconstructive surgery as a result of mastectomy
Breast reduction (if deemed medically necessary by a doctor)
Eyeglasses
Laser eye surgery
Seeing eye dog
Wheelchair
Crutches
Inclinator
Capital expenditures, operation and maintenance for permanent improvement or
betterment of the property advised by a physician (example, an elevator for an
afflicted individual), limited to the difference between the increase in property
value due to the improvement and the cost of installing the improvement.
Qualified long-term care services defined as: necessary diagnostic, preventative,
therapeutic, curing, treating, mitigating, and rehabilitative services, and
maintenance or personal care services, that are required by a chronically ill person
as certified by a healthcare practitioner. An individual is “chronically ill” if he/she
is as unable to perform at least 2 activities of daily living (e.g., eating, toileting,
transferring, bathing, dressing, and continence); or requires substantial
supervision to protect the individual’s health and safety due to severe cognitive
impairment as indicated in writing by a health care professional stating that it is
necessary for long term care.
Costs (tuition, meals and lodging) of attending a school that furnishes special
education to help a child to overcome learning disabilities caused by mental or
physical impairments. A doctor must recommend that the child attend the school.
Overcoming the learning disability must be a principal reason for attending the
school, and any ordinary education received must be incidental to the special
education provided. Special education includes but is not necessarily limited to:
- Teaching Braille to a visually impaired person,
-
•
•
Teaching lip reading to a hearing-impaired person, or
Giving remedial language training to correct a condition caused by a
birth defect.
Medical insurance premiums
Premium payments under a qualified long-term care insurance contract.
Note that the payment of qualified long-term care premiums is limited to the
following amounts:
Age before the Close of the Taxable Year
The limitation is:
40 or less
More than 40 but not more than 50
More than 70
$340
$640
$1,270
$3,390
$4,240
Note: Each of the above dollar amounts may be increased by the medical care cost
adjustment (as prescribed by the Treasury Secretary) each calendar year. Any increase
that is not a multiple of 10, shall be rounded to the nearest multiple of 10.
B. You cannot receive a hardship distribution for the following Medical Care expenses:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Babysitting, childcare and nursing services for a normal, healthy baby
Contributions to, or expenses that would be covered by, your flexible spending
account or health savings account or medical savings account
Controlled substances (such as marijuana, laetrile, etc.)
Cosmetic surgery (amount you pay for unnecessary surgery)
Dancing lessons
Diaper service
Electrolysis or hair removal
Funeral expenses (cannot include in medical expenses amounts you pay for
funerals)
Future medical care (to be provided substantially beyond the end of the year)
Hair transplant
Health club dues
Health coverage tax credit
Household help (not including nursing-type services)
Illegal operations and treatments
Insurance policies providing indemnity against loss of income or for loss or life,
limb, sight
Maternity clothes
Medicines and drugs from other countries
Nonprescription drugs and medicines (except insulin)
Nutritional supplements
Personal use items (toiletries, cosmetics, or sundry items)
Swimming lessons
•
•
•
Teeth whitening
Veterinary fees
Weight-loss program
Please see Internal Revenue Service Publication 502 for additional details regarding
what will, and what will not, constitute a medical expense that is eligible to be
covered by a hardship distribution.
C. If you request a hardship distribution for medical expenses, you must have
documentation to support your request. If you cannot produce the documentation to
substantiate your hardship request, your application will be denied. The following
documentation is acceptable:
1. Some Medical Care expenses are paid for by the insurance company. Others
are not. For the portion of those Medical Care expenses that the insurance
company will not pay (unreimbursed qualifying Medical Care expenses):
•
•
Current bill for service, and
Explanation of Benefits* for each bill submitted indicating:
• Service rendered that qualifies as a Medical Care expense;
• Date of such service;
• Amount of coverage paid; and
• Amount currently owed.
• If you cannot produce an Explanation of Benefits, you must
obtain a copy from the insurance company. If the company
cannot provide a copy, you may submit a copy of the medical
history with respect to the service rendered, including any
amount paid by the insurance company.
*If the Bill for service outlines the services rendered, you do not need to provide the
Explanation of Benefits documentation.
2. Some Medical Care expenses will not be covered at all by the insurance company.
For qualifying Medical Care expenses for treatment not covered by the insurance
policy:
•
•
•
A current bill for service that lists the information noted in item #1 above;
Explanation of Benefits evidencing a denial of coverage; or
A letter from the insurance company stating that no Explanation of Benefits is
available.
3. If prepayment of certain Medical Care expenses is required on or before the time
of treatment:
•
Estimate of the cost for the procedure from the insurance company and/or
medical professional
•
Letter from the medical professional stating that payment is required either in
advance or at the time of the procedure
An example of this would be were a dentist requires pre-payment for a treatment
plan.
Generally, you cannot include in medical expenses current payments for medical
care (including medical insurance) to be provided substantially beyond the end of
the year. This rule does not apply in situations where the future care is purchased
in connection with obtaining lifetime care or long-term care.
4. If Medical Care expenses will be paid in installments:
•
•
Explanation of Benefits evidencing the service rendered and that the lifetime
maximum permitted by the insurance company has been reached for the
applicable medical expense
A current bill showing the remaining amount to be paid. If the current bill
does not show the details of the specific service provided, please also provide
the original bill that provides that information.
D. Examples:
Past-due medical expenses: Past-due medical expenses may be eligible for hardship
treatment if the participant can produce bills for service dating back from the original
date of services to the current date that the participant is requesting the hardship. For
example, a participant incurs eligible medical care expenses on January 1st and has been
unable to pay them. On April 1st, the participant requests a hardship distribution to pay
the medical expenses. The participant will be required to produce documentation
indicating that the services were rendered and the amount is past due. Past due medical
expenses without proof that they are still owed will not be considered an immediate and
heavy financial need.
Important note: A bill shall be considered current if issued within 60 days from the
date of the hardship request.
Medical Credit Cards: Amounts owed on medical credit cards used to pay eligible
medical expenses are eligible for a hardship distribution. The amount of hardship shall be
limited to the amount necessary to satisfy payment of the eligible medical expenses
charged to the credit card.
Note: An Explanation of Benefits must be provided along with a copy of the medical
credit card bill.
Other Credit Cards: Balances for eligible medical expenses charged to all other credits
cards shall NOT be eligible for a hardship distribution.
II.
Purchase of a Principal Residence
A. Principal Residence includes:
•
•
•
•
Principal Residence
The purchase of land upon which the principal residence shall be immediately
built
Building a residence with a service contract
Purchase of a housing cooperative or condominium
B. Principal Residence DOES NOT include:
•
•
•
Vacation homes
Rental properties
Mortgage payments.
Note: The property may NOT be a rent-to-own residence or “lease with an option to
buy” residence.
C. If you request a hardship distribution for the purchase of a principal residence, you
must have documentation to support your request. If you cannot produce the
documentation to substantiate your hardship request, your application will be denied.
Any one of the following types documentation is acceptable:
•
Good Faith Estimate: Issued by a bank or mortgage company. The Good Faith
Estimate must include the estimated total closing costs, any down payments,
prepaid expenses and signature, excluding any contributions from the seller. The
Good Faith Estimate cannot be issued by a realty company (unless the real estate
agent is acting as the lender) and must be prepared and signed within 60 days of
the request.
*A contract is needed along with the Good Faith Estimate if the requested
withdrawal amount is more than the funds necessary to close indicated on the
Good Faith Estimate.
•
Contract: Must include a closing date (or, alternatively, written certification from
the mortgage company of the closing date); it must be issued no more than 60
days prior to the closing date; it must be signed by you and the seller.
*If the property is being financed by the owner, a Good Faith Estimate is not
required. A copy of the contract will suffice.
•
Service Contract: Must provide an estimated completion date; and it must be
signed by you and the contractor.
•
Purchase of land: For the construction of a principal residence, you must provide
MassMutual with an executed Contract between you and the seller (which may
include dates and amounts of periodic disbursements to the builder), a copy of the
construction loan and a commitment letter from a bank or mortgage company.
D. Examples:
Purchase of Land for Motor Home/Trailer: The purchase of land for purposes of
maintaining a motor home/trailer as the primary residence shall be eligible for a hardship
distribution when accompanied by one of the applicable documents noted in Section C
above.
Rent-to-Own Arrangements: Rental payments or “lease with an option to buy”
payments applied towards home ownership shall NOT be considered hardship eligible.
However, such payments may qualify for hardship if they are necessary to prevent
eviction from principal residence.
Building Ones Own Primary Residence: Hardship distributions will NOT be eligible if
you are building your own primary residence and are requesting a distribution to
purchase materials/services without a service contract.
Credit Card Expenses: A hardship distribution will NOT be allowed for expenses that
are charged to a credit card.
III.
Payment of Tuition and Related Educational Fees
A. You may receive a hardship distribution for the following fees and expenses:
•
•
•
Tuition
Related educational fees, including books
Room and board expenses
A hardship distribution may be permitted to cover expenses related to the current
semester or to cover past overdue balances from previous semesters (provided the
balance is still outstanding and a current bill is provided). The above bulleted expenses
may be forecasted out up to the next 12 months of post-secondary education.
B. The fees and expenses must be incurred by one of the following accredited
institutions which must also require a high school diploma or recognized equivalent
for admission:
•
•
•
•
State-sponsored university
State-sponsored college
State-sponsored vocational school
State-sponsored technical school
•
•
•
•
Private university
Private college
Private vocational school (examples: tractor trailer, cosmetology, escalator
technician)
Private technical school
C. Tuition and related educational expenses shall not include:
•
•
•
Non-academic-related expenses
Courses designed to sell products (ex. real estate courses)
Random courses that are not part of, or result in completion of, a program that
provides a certification or degree.
D. If you request a hardship distribution for tuition and related educational fees, you
must have documentation to support your request. MassMutual may require that you
produce this documentation at any time. If you cannot produce the documentation to
For initial, ongoing enrollment and summer sessions:
•
A current tuition bill listing the school name indicating:
- Name of the student
- Total amount currently outstanding (not just the cost of attending the school)
- The semester or term the charges are for
- Whether expenses for room and board are included in the hardship request
•
The tuition bill may also be used to calculate anticipated financial need for the
remainder of the academic year.
E. Examples:
Off-campus Housing: Off campus housing is eligible for a financial hardship, provided
that the housing is affiliated with the educational institution the student is attending. A
copy of the rental agreement or lease agreement is required with the student’s name or a
letter from the landlord stating the student will reside there. If there is more than one
leasee it must specify how much each party is responsible to pay. Expenses outside of the
lease agreement, such as internet, phone and cable service bills, are not reimbursable.
Secondary Education Fees: Preschool, elementary, middle or high school tuition and
related educational expenses are not hardship eligible.
IV.
Prevention of Eviction or Foreclosure
A. You may receive a hardship if the distribution is necessary for the following:
• To prevent eviction from the employee’s principal residence
• To prevent foreclosure on the mortgage on that residence.
• The amount of the hardship may be in an amount sufficient to bring all payments
current as of the date such funds are received.
B. If you request a hardship distribution to prevent eviction or foreclosure, you must
have documentation to support your request. If you cannot produce the
The following documentation is acceptable:
1. Eviction from the principal residence:
• Eviction notice issued by the landlord, apartment complex, court, or any other
authorized entity which states the amount to be paid to prevent eviction and
that such amount is past due.
If the eviction notice is issued by an individual rather than a rental organization,
you must also supply MassMutual with a copy of the lease agreement and a
signed statement from the landlord confirming the pending eviction. If there is no
written lease agreement involved, a signed statement from the landlord
confirming the pending eviction will be required, and such statement must also
specify the residential address of the property, the monthly rental amount and that
there is no lease agreement.
2. Foreclosure on the principal residence:
•
Notice of foreclosure (stating that proceedings have commenced or will
commence either immediately or on a specified date), which must:
- Be issued by a bank, mortgage company, or other qualified lending institution
- State the amount due to bring the mortgage current, and
- State that foreclosure proceedings will commence immediately if the amounts
owed are not paid.
C. Examples:
Eviction from Land: Evicted from the lot upon which your trailer is located and the
trailer is your primary residence.
Timely Hardship Application: The eviction or foreclosure notice must not be past the
eviction/foreclosure date. The eviction deadline must allow time for review and
processing – MassMutual requests that requests are submitted at least five business days
before the eviction date on the notice.
Cure of Foreclosure: If foreclosure proceedings have begun, a letter from the mortgage
company stating the amount that is required to cure the foreclosure shall be considered to
be evidence of an immediate and heavy financial need. A hardship distribution will not
be permitted beyond the amount necessary to cure the foreclosure.
If foreclosure or the immediate threat of foreclosure is due to non-payment of property
taxes then a hardship distribution will be permitted if the required supporting
documentation is provided.
Note: If the mortgage is not in the participant’s name but the deed is and has the same
address or if the mortgage and the deed are in the spouse’s name and the address is the
participant’s address then a hardship distribution will be permitted if the required
supporting documentation is provided.
V.
Burial and/or Funeral Expenses
A. You may receive a hardship distribution for the following items:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
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•
Purchase of grave
Burial fees
Monument fees (headstone)
Crematory fees
Casket
Casket fittings
Burial containers
Urn
Nameplates
Memorial plaque
Book of remembrance
Memorial cards
Church fees
Press notices
Cemetery fees
Services for funeral director, staff and overhead
Hearse and funeral vehicle rentals necessary to transport the deceased (does not
include transportation of family members)
Collection of the body and transference to hospital, funeral home/mortuary or
other location
Preparation of the body
Embalming
Memorial service
Graveside service
Funeral service
B. You cannot receive a hardship distribution for the following burial and/or funeral
expenses:
•
•
•
•
•
Reception
Flowers
Donations
Pre-payment of a (future) funeral
Transportation (other than the modes of transportation not included in Section A
above).
C. If you request a hardship distribution for the payment of funeral or burial expenses,
you must have documentation to support your request. If you cannot produce the
The following documentation is acceptable:
•
A current bill for burial and/or funeral expenses indicating:
°
Name of the funeral home, mortuary, crematorium, cemetery,
monument company and/or religious establishment (church,
synagogue, chapel or other place of worship)
°
Name of the parent, spouse, child or other dependent on whose
behalf the services were furnished. If the decedent’s name is not
included in the bill for service, additionally, the participant must
provide a death certificate indicating the decedent’s name. Unless
the person is a dependent (as described at the beginning of this
document), the following relationships would not qualify for
reimbursement: brother or sister in-law, mother or father in-law.
°
List of expenses incurred
D. Examples:
Credit Card Expenses: A hardship distribution will NOT be allowed to pay for burial or
funeral expenses that are charged to a credit card.
VI. Expenses for the Repair of Damage to the Employee’s
Principal Residence that would Qualify for the Casualty Deduction
A. You may receive a hardship distribution to repair damage to your principal residence
that arose from any of the following sudden, unexpected or unusual events:
•
•
•
Electrical storms
Tree damage (ex. Limb punctures roof)
Earthquakes
•
•
•
•
•
•
•
•
•
•
•
•
•
Fires
Floods (such as riverbanks overflowing or floods that impact a community)
Government-ordered demolition or relocation of a home that is unsafe to use
because of a disaster
Hail
Landslides
Mine cave-ins
Shipwrecks
Sonic booms
Hurricanes and tornadoes
Terrorist attacks
Vandalism
Volcanic eruptions
Disasters occurring in an area subsequently determined by the President of the
United States to warrant assistance by the Federal Government
Note: Your insurance deductible amount may qualify for a hardship.
This list contains examples of casualties that qualify for a hardship, but this list is
not all-inclusive of every casualty that may be covered.
B. The following items do not qualify for hardship treatment:
Progressive deterioration:
•
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•
•
•
The steady weakening of a building due to normal wind and weather conditions;
A burst water heater (however, the rust and water damage to rugs and drapes
caused by the bursting of a water heater does qualify as a casualty)
Losses caused by droughts
Termite or moth damage
The damage or destruction of trees, shrubs and other plans by a fungus, disease,
insects, worms or similar pests
C. If you request a hardship distribution for the repair or construction of your principal
residence due to damage caused by a qualifying casualty, you must have
documentation to support your request. If you cannot produce the documentation to
1. For the payment of unreimbursed costs of qualifying casualties to repair a
damaged principal residence:
•
Bill for services from the contractor. The contractor should state the cause of
the casualty and provide a breakdown of the cost on the bill
•
Statement from the insurance carrier evidencing a denial of coverage* of the
cost of repairs
2. If you are required to prepay certain repairs/construction:
•
•
Estimate from the contractor. The contractor should state the cause of the
casualty on the estimate.
Statement from the insurance carrier evidencing the coverage* or the denial of
coverage of the costs of repair
3. For the building of a principal residence destroyed by the casualty:
•
•
Executed contract between you and the contractor (which may include dates
and amounts of periodic disbursements to the contractor). The contractor
should state the cause of the casualty on the contract.
Statement from the insurance carrier evidencing the coverage or the denial of
coverage* of the cost of construction
*Insurance claims that are denied because the insurance carrier has labeled the loss due to
“normal wear and tear” or because it deems the loss to be the result of an incident outside
the definition of casualty as defined in Section A. above will not qualify as a hardship.
RS-07480-09
Exp. 01/01/14
Distributions Forms –
Defined Contribution Plans
SPECIAL TAX NOTICE
(For Payments Not From a Designated Roth Account)
YOUR ROLLOVER OPTIONS
You are receiving this notice because all or a portion of a payment you are receiving from your retirement
plan is eligible to be rolled over to an IRA or an employer plan. This notice is intended to help you decide
whether to do such a rollover.
This notice describes the rollover rules that apply to payments from the Plan that are not from a
designated Roth account (a type of account with special tax rules in some employer plans). If you also
receive a payment from a designated Roth account in the Plan, you will be provided a different notice for
that payment, and the Plan administrator or the payor will tell you the amount that is being paid from each
account.
Rules that apply to most payments from a plan are described in the “General Information About
Rollovers” section. Special rules that only apply in certain circumstances are described in the “Special
Rules and Options” section.
GENERAL INFORMATION ABOUT ROLLOVERS
How can a rollover affect my taxes?
You will be taxed on a payment from the Plan if you do not roll it over. If you are under age 59½ and do
not do a rollover, you will also have to pay a 10% additional income tax on early distributions (unless an
exception applies). However, if you do a rollover, you will not have to pay tax until you receive payments
later and the 10% additional income tax will not apply if those payments are made after you are age 59½
(or if an exception applies).
Where may I roll over the payment?
You may roll over the payment to either an IRA (an individual retirement account or individual retirement
annuity) or an employer plan (a tax-qualified plan, section 403(b) plan, or governmental section 457(b)
plan) that will accept the rollover. The rules of the IRA or employer plan that holds the rollover will
determine your investment options, fees, and rights to payment from the IRA or employer plan (for
example, no spousal consent rules apply to IRAs and IRAs may not provide loans). Further, the amount
rolled over will become subject to the tax rules that apply to the IRA or employer plan.
How do I do a rollover?
There are two ways to do a rollover. You can do either a direct rollover or a 60-day rollover.
 If you do a direct rollover, the Plan will make the payment directly to your IRA or an employer
plan. You should contact the IRA sponsor or the administrator of the employer plan for
information on how to do a direct rollover.

If you do not do a direct rollover, you may still do a rollover by making a deposit into an IRA or
eligible employer plan that will accept it. You will have 60 days after you receive the payment to
make the deposit. If you do not do a direct rollover, the Plan is required to withhold 20% of the
payment for federal income taxes (up to the amount of cash and property received other than
employer stock). This means that, in order to roll over the entire payment in a 60-day rollover, you
RS‐31234‐00 Distributions Forms –
Defined Contribution Plans must use other funds to make up for the 20% withheld. If you do not roll over the entire amount of
the payment, the portion not rolled over will be taxed and will be subject to the 10% additional
income tax on early distributions if you are under age 59½ (unless an exception applies).
How much may I roll over?
If you wish to do a rollover, you may roll over all or part of the amount eligible for rollover. Any payment
from the Plan is eligible for rollover, except:
•
•
•
•
•
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•
•
•
•
Certain payments spread over a period of at least 10 years or over your life or life expectancy (or the
lives or joint life expectancy of you and your beneficiary)
Required minimum distributions after age 70½ (or after death)
Hardship distributions
ESOP dividends
Corrective distributions of contributions that exceed tax law limitations
Loans treated as deemed distributions (for example, loans in default due to missed payments before
your employment ends)
Cost of life insurance paid by the Plan
Contributions made under special automatic enrollment rules that are withdrawn pursuant to your
request within 90 days of enrollment
Amounts treated as distributed because of a prohibited allocation of S corporation stock under an
ESOP (also, there will generally be adverse tax consequences if you roll over a distribution of S
corporation stock to an IRA).
If you are doing an In Plan Roth Rollover only vested amounts held in a plan account for a plan
participant other than an amount held in a designated Roth account is eligible to be rolled over to the
same plan.
The Plan administrator or the payor can tell you what portion of a payment is eligible for rollover.
If I don’t do a rollover, will I have to pay the 10% additional income tax on early distributions?
If you are under age 59½, you will have to pay the 10% additional income tax on early distributions for
any payment from the Plan (including amounts withheld for income tax) that you do not roll over, unless
one of the exceptions listed below applies. This tax is in addition to the regular income tax on the
payment not rolled over.
The 10% additional income tax does not apply to the following payments from the Plan:
•
•
•
•
•
•
•
•
•
Payments made after you separate from service if you will be at least age 55 in the year of the
separation
Payments that start after you separate from service if paid at least annually in equal or close to equal
amounts over your life or life expectancy (or the lives or joint life expectancy of you and your
beneficiary)
Payments from a governmental defined benefit pension plan made after you separate from service if
you are a public safety employee and you are at least age 50 in the year of the separation
Payments made due to disability
Payments after your death
Payments of ESOP dividends
Corrective distributions of contributions that exceed tax law limitations
Cost of life insurance paid by the Plan
Contributions made under special automatic enrollment rules that are withdrawn pursuant to your
request within 90 days of enrollment
104A-2
11/09
•
•
•
•
•
Payments made directly to the government to satisfy a federal tax levy
Payments made under a qualified domestic relations order (QDRO)
Payments up to the amount of your deductible medical expenses
Certain payments made while you are on active duty if you were a member of a reserve component
called to duty after September 11, 2001 for more than 179 days
Payments of certain automatic enrollment contributions requested to be withdrawn within 90 days of
the first contribution.
If I do a rollover to an IRA, will the 10% additional income tax apply to early distributions from
the IRA?
If you receive a payment from an IRA when you are under age 59½, you will have to pay the 10%
additional income tax on early distributions from the IRA, unless an exception applies. In general, the
exceptions to the 10% additional income tax for early distributions from an IRA are the same as the
exceptions listed above for early distributions from a plan. However, there are a few differences for
payments from an IRA, including:
•
•
•
•
There is no exception for payments after separation from service that are made after age 55.
The exception for qualified domestic relations orders (QDROs) does not apply (although a special
rule applies under which, as part of a divorce or separation agreement, a tax-free transfer may be
made directly to an IRA of a spouse or former spouse).
The exception for payments made at least annually in equal or close to equal amounts over a specified
period applies without regard to whether you have had a separation from service.
There are additional exceptions for (1) payments for qualified higher education expenses, (2)
payments up to $10,000 used in a qualified first-time home purchase, and (3) payments after you have
received unemployment compensation for 12 consecutive weeks (or would have been eligible to
receive unemployment compensation but for self-employed status).
Will I owe State, Local or U.S. possession income taxes?
This notice does not describe any state, local or U.S. possession income tax rules (including withholding
rules).
SPECIAL RULES AND OPTIONS
If your payment includes after-tax contributions
After-tax contributions included in a payment are not taxed. If a payment is only part of your benefit, an
allocable portion of your after-tax contributions is generally included in the payment. If you have pre1987 after-tax contributions maintained in a separate account, a special rule may apply to determine
whether the after-tax contributions are included in a payment.
You may roll over to an IRA a payment that includes after-tax contributions through either a direct
rollover or a 60-day rollover. You must keep track of the aggregate amount of the after-tax contributions
in all of your IRAs (in order to determine your taxable income for later payments from the IRAs). If you
do a direct rollover of only a portion of the amount paid from the Plan and a portion is paid to you, each
of the payments will include an allocable portion of the after-tax contributions. If you do a 60day rollover
to an IRA of only a portion of the payment made to you, the after-tax contributions are treated as rolled
over last. For example, assume you are receiving a complete distribution of your benefit which totals
$12,000, of which $2,000 is after-tax contributions. In this case, if you roll over $10,000 to an IRA in a
Defined Contribution Plans 60-day rollover, no amount is taxable because the $2,000 amount not rolled over is treated as being aftertax contributions.
You may roll over to an employer plan all of a payment that includes after-tax contributions, but only
through a direct rollover (and only if the receiving plan separately accounts for after-tax contributions and
is not a governmental section 457(b) plan). You can do a 60-day rollover to an employer plan of part of a
payment that includes after-tax contributions, but only up to the amount of the payment that would be
taxable if not rolled over.
If you miss the 60-day rollover deadline
Generally, the 60-day rollover deadline cannot be extended. However, the IRS has the limited authority to
waive the deadline under certain extraordinary circumstances, such as when external events prevented
you from completing the rollover by the 60-day rollover deadline. To apply for a waiver, you must file a
private letter ruling request with
the IRS. Private letter ruling requests require the payment of a nonrefundable user fee. For more
information, see IRS Publication 590, Individual Retirement Arrangements (IRAs).
If your payment includes employer stock that you do not roll over
If you do not do a rollover, you can apply a special rule to payments of employer stock (or other employer
securities) that are either attributable to after-tax contributions or paid in a lump sum after separation from
service (or after age 59½, disability, or the participant’s death). Under the special rule, the net unrealized
appreciation on the stock will not be taxed when distributed from the Plan and will be taxed at capital
gain rates when you sell the stock. Net unrealized appreciation is generally the increase in the value of
employer stock after it was acquired by the Plan. If you do a rollover for a payment that includes
employer stock (for example, by selling the stock and rolling over the proceeds within 60 days of the
payment), the special rule relating to the distributed employer stock will not apply to any subsequent
payments from the IRA or employer plan. The Plan administrator can tell you the amount of any net
unrealized appreciation.
If you have an outstanding loan that is being offset
If you have an outstanding loan from the Plan, your Plan benefit may be offset by the amount of the loan,
typically when your employment ends. The loan offset amount is treated as a distribution to you at the
time of the offset and will be taxed (including the 10% additional income tax on early distributions,
unless an exception applies) unless you do a 60-day rollover in the amount of the loan offset to an IRA or
employer plan.
If you were born on or before January 1, 1936
If you were born on or before January 1, 1936 and receive a lump sum distribution that you do not roll
over, special rules for calculating the amount of the tax on the payment might apply to you. For more
information, see IRS Publication 575, Pension and Annuity Income.
If your payment is from a governmental section 457(b) plan
If the Plan is a governmental section 457(b) plan, the same rules described elsewhere in this notice
generally apply, allowing you to roll over the payment to an IRA or an employer plan that accepts
rollovers. One difference is that, if you do not do a rollover, you will not have to pay the 10% additional
income tax on early distributions from the Plan even if you are under age 59½ (unless the payment is
104A-4
11/09
from a separate account holding rollover contributions that were made to the Plan from a tax-qualified
plan, a section 403(b) plan, or an IRA). However, if you do a rollover to an IRA or to an employer plan
that is not a governmental section 457(b) plan, a later distribution made before age 59½ will be subject to
the 10% additional income tax on early distributions (unless an exception applies). Other differences are
that you cannot do a rollover if the payment is due to an “unforeseeable emergency” and the special rules
under “If your payment includes employer stock that you do not roll over” and “If you were born on or
before January 1, 1936” do not apply.
If you are an eligible retired public safety officer and your pension payment is used to pay for
health coverage or qualified long-term care insurance
If the Plan is a governmental plan, you retired as a public safety officer, and your retirement was by
reason of disability or was after normal retirement age, you can exclude from your taxable income plan
payments paid directly as premiums to an accident or health plan (or a qualified long-term care insurance
contract) that your employer maintains for you, your spouse, or your dependents, up to a maximum of
$3,000 annually. For this purpose, a public safety officer is a law enforcement officer, firefighter,
chaplain, or member of a rescue squad or ambulance crew.
If you roll over your payment to a Roth IRA
If you roll over the payment to a Roth IRA, a special rule applies under which the amount of the payment
rolled over (reduced by any after-tax amounts) will be taxed. However, the 10% additional income tax on
early distributions will not apply (unless you take the amount rolled over out of the Roth IRA within 5
years, counting from January 1 of the year of the rollover). For payments from the Plan during 2010 that
are rolled over to a Roth IRA, the taxable amount can be spread over a 2-year period starting in 2011.
If you roll over the payment to a Roth IRA, later payments from the Roth IRA that are qualified
distributions will not be taxed (including earnings after the rollover). A qualified distribution from a Roth
IRA is a payment made after you are age 59½ (or after your death or disability, or as a qualified first-time
homebuyer distribution of up to $10,000) and after you have had a Roth IRA for at least 5 years. In
applying this 5-year rule, you count from January 1 of the year for which your first contribution was made
to a Roth IRA. Payments from the Roth IRA that are not qualified distributions will be taxed to the extent
of earnings after the rollover, including the 10% additional income tax on early distributions (unless an
exception applies). You do not have to take required minimum distributions from a Roth IRA during your
lifetime. For more information, see IRS Publication 590, Individual Retirement Arrangements (IRAs).
If you roll over your payment to an in-plan Roth Rollover
If the distributee rolls over the payment to a designated Roth account in the plan, the amount of the
payment rolled over (reduced by any after-tax amounts directly rolled over) will be taxed. However, the
10% additional tax on early distributions will not apply (unless the distributee takes the amount rolled
over out of the designated Roth account within the 5-year period that begins on January 1 of the year of
the rollover). For payments from the plan in 2010 that are rolled over to a designated Roth account in
the plan (and that are not distributed from that account until after 2011), the taxable amount of the
rollover will be taxed half in 2011 and half in 2012, unless the distributee elects to be taxed in 2010.
If the distributee rolls over the payment to a designated Roth account in the plan, later payments from the
designated Roth account that are qualified distributions will not be taxed (including earnings after the
rollover). A qualified distribution from a designated Roth account is a payment made both after the
distributee attains age 59½ (or after the distributee’s death or disability) and after the distributee has had a
Defined Contribution Plans designated Roth account in the plan for a period of at least 5 years. The 5-year period described in the
preceding sentence begins on January 1 of the year the distributee’s first contribution was made to the
designated Roth account. However, if the distributee made a direct rollover to a designated Roth account
in the plan from a designated Roth account in a plan of another employer, the 5-year period begins on
January 1 of the year the distributee’s first contribution was made to the designated Roth account in the
plan or, if earlier, to the designated Roth account in the plan of the other employer. Payments from the
designated Roth account that are not qualified distributions will be taxed to the extent allocable to
earnings after the rollover, including the 10% additional tax on early distributions (unless an exception
applies).
If you are not a plan participant
Payments after death of the participant. If you receive a distribution after the participant’s death that you
do not roll over, the distribution will generally be taxed in the same manner described elsewhere in this
notice. However, the 10% additional income tax on early distributions and the special rules for public
safety officers do not apply, and the special rule described under the section “If you were born on or
before January 1, 1936” applies only if the participant was born on or before January 1, 1936.
If you are a surviving spouse. If you receive a payment from the Plan as the surviving spouse of a
deceased participant, you have the same rollover options that the participant would have had, as
described elsewhere in this notice. In addition, if you choose to do a rollover to an IRA, you may treat
the IRA as your own or as an inherited IRA.
An IRA you treat as your own is treated like any other IRA of yours, so that payments made to you
before you are age 59½ will be subject to the 10% additional income tax on early distributions (unless
an exception applies) and required minimum distributions from your IRA do not have to start until
after you are age 70½.
If you treat the IRA as an inherited IRA, payments from the IRA will not be subject to the 10%
additional income tax on early distributions. However, if the participant had started taking required
minimum distributions, you will have to receive required minimum distributions from the inherited
IRA. If the participant had not started taking required minimum distributions from the Plan, you will
not have to start receiving required minimum distributions from the inherited IRA until the year the
participant would have been age 70½.
If you are a surviving beneficiary other than a spouse. If you receive a payment from the Plan
because of the participant’s death and you are a designated beneficiary other than a surviving spouse,
the only rollover option you have is to do a direct rollover to an inherited IRA. Payments from the
inherited IRA will not be subject to the 10% additional income tax on early distributions. You will
have to receive required minimum distributions from the inherited IRA.
Payments under a qualified domestic relations order. If you are the spouse or former spouse of the
participant who receives a payment from the Plan under a qualified domestic relations order (QDRO), you
generally have the same options the participant would have (for example, you may roll over the payment
to your own IRA or an eligible employer plan that will accept it). Payments under the QDRO will not be
subject to the 10% additional income tax on early distributions.
If you are a nonresident alien
If you are a nonresident alien and you do not do a direct rollover to a U.S. IRA or U.S. employer plan,
instead of withholding 20%, the Plan is generally required to withhold 30% of the payment for federal
income taxes. If the amount withheld exceeds the amount of tax you owe (as may happen if you do a 60 104A-6
11/09
day rollover), you may request an income tax refund by filing Form 1040NR and attaching your Form
1042-S. See Form W-8BEN for claiming that you are entitled to a reduced rate of withholding under an
income tax treaty. For more information, see also IRS Publication 519, U.S. Tax Guide for Aliens, and
IRS Publication 515, Withholding of Tax on Nonresident Aliens and Foreign Entities.
Other special rules
If a payment is one in a series of payments for less than 10 years, your choice whether to make a direct
rollover will apply to all later payments in the series (unless you make a different choice for later
payments).
If your payments for the year are less than $200 (not including payments from a designated Roth account
in the Plan), the Plan is not required to allow you to do a direct rollover and is not required to withhold for
federal income taxes. However, you may do a 60-day rollover.
Unless you elect otherwise, a mandatory cashout of more than $1,000 (not including payments from a
designated Roth account in the Plan) will be directly rolled over to an IRA chosen by the Plan
administrator or the payor. A mandatory cashout is a payment from a plan to a participant made before
age 62 (or normal retirement age, if later) and without consent, where the participant’s benefit does not
exceed $5,000 (not including any amounts held under the plan as a result of a prior rollover made to the
plan).
You may have special rollover rights if you recently served in the U.S. Armed Forces. For more
information, see IRS Publication 3, Armed Forces’ Tax Guide.
FOR MORE INFORMATION
This notice summarizes only the federal (not state, local or U. S. possession) tax rules that might
apply to your payment. You may wish to consult with the Plan administrator, or a professional tax
advisor, before taking a payment from the Plan. Also, you can find more detailed information on the
federal tax treatment of payments from employer plans in: IRS Publication 575, Pension and Annuity
Income; IRS Publication 590, Individual Retirement Arrangements (IRAs); IRS Publication 570, Tax
Guide for Individuals With Income From U.S. Possessions; and IRS Publication 571, Tax-Sheltered
Annuity Plans (403(b) Plans). These publications are available from a local IRS office, on the web at
www.irs.gov, or by calling 1-800-TAX-FORM.
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RS‐31234‐00 *
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State Tax Information
The information contained in this document is not intended or written as specific legal or tax advice
and may not be relied on for purposes of avoiding any state tax penalties. Neither MassMutual nor
any of its employees or representatives are authorized to give legal or tax advice. You must rely on
the advice of your own independent tax counsel.
State tax withholding is based on your legal state of residence.
MassMutual will not withhold state taxes if the amount of withholding is less than $10.
Mandatory state withholding
State taxes that are required to be withheld per state tax regulations. In some states, a payee can opt out of
mandatory state withholding if requested in writing. (Your distribution form constitutes a request “in
writing.”)
Voluntary state withholding
State taxes that are not required to be withheld but may be requested by the participant.
What is a periodic payment?
A series of payments made at regular intervals over a certain term of years, for example, annuities or
installments payments.
What is a non-periodic payment?
A single-sum payment that is paid at one time.
(c) 2012 - Massachusetts Mutual Life Insurance Company, Springfield, MA. All rights reserved. Effective 10/1/2012
RS 07262.pdf v 6.14
RS 18096-08
LEGAL STATE OF
RESIDENCE
STATE TAX WITHHOLDING REGULATIONS
ALABAMA
Alabama state withholding is voluntary. If you elect to have state taxes withheld, select
“Voluntary State Income Tax Withholding” and enter a dollar amount or percentage. If
you select “Voluntary State Income Tax Withholding” and do not enter a dollar amount
or percentage, MassMutual will not withhold any state taxes.
ALASKA
Alaska does not have personal income tax. State tax will not be withheld from any
distribution.
ARIZONA
Lump-sum/non-periodic payments: There are no state tax provisions for non-periodic
distributions. State tax will not be withheld from these distributions.
Periodic payments (installment payments):
Arizona state withholding on periodic payments is voluntary; you may elect to have state
taxes withheld only if federal taxes are withheld. If you request to have state taxes
withheld, select “Voluntary State Income Tax Withholding.” You must enter one of the
following percentages:
0.8%, 1.3, 1.8%, 2.7%, 3.6%, 4.2% or 5.1%.
If you select “Voluntary State Income Tax Withholding” and do not enter one of these
percentages, MassMutual will not withhold any state taxes.
ARKANSAS
Arkansas state tax withholding is mandatory if your distribution is eligible for rollover
and will be calculated as 5% of the taxable distribution. Special rules apply for
distributions that are not eligible for rollover.
You may also request an additional amount to be withheld by selecting ‘Additional State
Income Tax Withholding’ on your distribution form and entering a dollar amount.
CALIFORNIA
California state tax withholding is mandatory if federal taxes are withheld. If no federal
taxes are withheld, no state taxes will be withheld. State taxes are calculated as 10% of
the federal amount withheld.
You may elect to have state taxes withheld even if there is no federal withholding by
selecting “Voluntary State Income Tax Withholding” and entering a dollar amount.
You may elect not to have state taxes withheld even if there is federal withholding by
selecting “No State Tax Withholding Election.”
COLORADO
Colorado state withholding voluntary. If you elect to have state taxes withheld, select
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CONNECTICUT
DELAWARE
Connecticut state withholding is voluntary. If you elect to have state taxes withheld,
select “Voluntary State Income Tax Withholding” and enter a whole dollar amount. If
you select “Voluntary State Income Tax Withholding” and do not enter a whole dollar
amount, MassMutual will round to the nearest whole dollar.
Delaware state tax withholding is mandatory if federal taxes are withheld. If no federal
taxes are withheld, no state taxes will be withheld. The amount withheld is calculated as
5% of the taxable distribution.
You may elect to have 5% state taxes, or greater, withheld even if there is no federal
withholding by selecting “Voluntary State Income Tax Withholding.”
DISTRICT OF
COLUMBIA
The District of Columbia state withholding is mandatory on all lump sum distributions of
a participant's entire account balance. For such distributions state taxes are withheld at
8.95%. For periodic and partial distributions state tax withholding is voluntary.
FLORIDA
Florida does not have personal income tax. State tax will not be withheld from any
distribution.
GEORGIA
Lump-sum/non-periodic payments:
Georgia state withholding is voluntary for non-periodic payments. If you elect to have
state taxes withheld, select “Voluntary State Income Tax Withholding” on your
distribution form, but do not enter a percentage or dollar amount. Georgia taxes are
withheld at a predetermined percentage depending on the amount of your distribution:
If distribution is
under $8,000
$8,000 - $10,000
$10,001 - $12,000
$12,001 - $15,000
Over $15,000
withholding is
2%
3%
4%
5%
6%
Periodic payments:
Georgia state tax withholding is mandatory if federal taxes are withheld. If no federal
taxes are withheld, no state taxes will be withheld.
selecting “Voluntary State Income Tax Withholding/based on my state's tax table
formula.”
You may elect not to have state taxes withheld even if there is federal withholding by
The amount withheld on periodic payments will be based on your state’s wage tables.
MassMutual will use your state’s default allowance.
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HAWAII
Hawaii state withholding is voluntary. If you elect to have state taxes withheld, select
IDAHO
Idaho state withholding is voluntary. If you elect to have state taxes withheld, select
ILLINOIS
Illinois state withholding is voluntary. If you elect to have state taxes withheld, select
INDIANA
Indiana state withholding is voluntary. If you elect to have state taxes withheld, select
“Voluntary State Income Tax Withholding” and enter a whole dollar amount. If you
select “Voluntary State Income Tax Withholding” and do not enter a whole dollar
amount, MassMutual will round to the nearest whole dollar. If you provide a percentage,
MassMutual will not withhold taxes.
IOWA
Iowa state tax withholding is mandatory if federal taxes are withheld. If no federal taxes
are withheld, no state taxes will be withheld. State taxes are withheld at 5% of the
taxable distribution.
You may elect to have 5%, or higher, state taxes withheld even if there is no federal
KANSAS
Kansas state tax withholding is mandatory if federal taxes are withheld. If no federal
taxes are withheld, no state taxes will be withheld. State taxes are withheld at 5% of the
KENTUCKY
Kentucky state withholding is voluntary. If you elect to have state taxes withheld, select
LOUISIANA
Louisiana state withholding is voluntary. If you elect to have state taxes withheld, select
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MAINE
Maine state tax withholding is mandatory if federal taxes are withheld. If no federal
taxes are withheld, no state taxes will be withheld. The amount withheld is 5% of the
MARYLAND
MASSACHUSETTS
Maryland state tax withholding is mandatory on periodic and non-periodic distributions
that are eligible for rollover. The amount withheld is 7.75% of the taxable distribution.
Special rules apply for distributions that are not eligible for rollover.
Massachusetts state tax withholding is mandatory if federal taxes are withheld. If no
federal taxes are withheld, no state taxes will be withheld. State taxes are withheld at
5.25% of the taxable distribution.
If you want a different amount withheld, please provide your marital status and the
number of exemptions you wish to claim on your distribution form.
MICHIGAN
MINNESOTA
Michigan state withholding is mandatory on periodic and non-periodic distributions.
The amount withheld is 4.25%. All or some of the distribution may be exempt from
Michigan state tax withholding, but you must provide a Michigan Form W-4P in those
instances. For more information regarding exemptions that may be available to you,
please consult your tax advisor and/or the Michigan Department of Treasury.
Lump-sum/non-periodic payments: Minnesota state withholding on non-periodic
payments is voluntary. If you elect to have state taxes withheld, select “Voluntary State
Income Tax Withholding” and enter a dollar amount or percentage. If you select
“Voluntary State Income Tax Withholding” and do not enter a dollar amount or
percentage, MassMutual will not withhold any state taxes.
For periodic payments: Minnesota state withholding on periodic payments is voluntary.
If you elect to have state taxes withheld, select “Voluntary State Income Tax
Withholding/ based on my state's tax table formula.”
MISSISSIPPI
Mississippi state withholding is voluntary. If you elect to have state taxes withheld,
select “Voluntary State Income Tax Withholding” and enter a dollar amount or
percentage. If you select “Voluntary State Income Tax Withholding” and do not enter a
dollar amount or percentage, MassMutual will not withhold any state taxes.
MISSOURI
Missouri state withholding is voluntary. If you elect to have state taxes withheld, select
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MONTANA
Montana state withholding is voluntary. If you elect to have state taxes withheld, select
“Voluntary State Income Tax Withholding” and enter a flat dollar amount. If you select
“Voluntary State Income Tax Withholding” and do not enter a flat dollar amount,
MassMutual will not withhold any state taxes.
NEBRASKA
Nebraska state tax withholding is mandatory if federal taxes are withheld. If no federal
selecting “Voluntary State Income Tax Withholding/ based on my state's tax table
formula.”
The amount withheld is 5% of the taxable distribution.
Periodic payments
NEVADA
NEW HAMPSHIRE
Nevada does not have personal income tax. State tax will not be withheld from any
distribution.
New Hampshire does not have personal income tax. State tax will not be withheld from
any distribution.
NEW JERSEY
New Jersey state withholding is voluntary. If you elect to have state taxes withheld,
select “Voluntary State Income Tax Withholding” and enter a whole dollar amount. If
you select “Voluntary State Income Tax Withholding” and do not enter a whole dollar
amount, MassMutual will round to the nearest whole dollar.
NEW MEXICO
New Mexico state withholding is voluntary. If you elect to have state taxes withheld,
NEW YORK
New York state withholding is voluntary. If you elect to have state taxes withheld,
NORTH CAROLINA
North Carolina state tax withholding is mandatory for distributions eligible for rollover
if federal taxes are withheld. If no federal taxes are withheld, no state taxes will be
withheld. Special rules apply for distributions that are not eligible for rollover. You
may elect to have state taxes withheld even if there is no federal withholding by selecting
“Voluntary State Income Tax Withholding.”
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The amount withheld on non-periodic payments is 4% of the taxable distribution.
Periodic payments
NORTH DAKOTA
North Dakota state withholding is voluntary. If you elect to have state taxes withheld,
OHIO
Lump-sum/non-periodic payments: Ohio state withholding is voluntary. If you elect to
have state taxes withheld, select “Voluntary State Tax Withholding” and enter a
percentage (not less than 3.5%). If you select “Voluntary State Tax Withholding” and do
not enter a percentage, MassMutual will not withhold any state taxes. If you enter a
percentage less than 3.5%, MassMutual will withhold 3.5%, your state’s minimum.
Periodic payments, Ohio state withholding is voluntary. If you elect to have state taxes
withheld, select “Voluntary State Income Tax Withholding/ based on my state's tax table
formula.”
OKLAHOMA
Oklahoma state tax withholding is mandatory if federal taxes are withheld. If no federal
selecting “Voluntary State Income Tax Withholding.”
Periodic payments
OREGON
Oregon state tax withholding is mandatory if federal taxes are withheld. If no federal
You may elect not to have state taxes withheld when there is federal withholding by
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The amount withheld is 8% of the taxable distribution and cannot be more than 10%.
Periodic payments
PENNSYLVANIA
Pennsylvania state withholding is voluntary. If you elect to have state taxes withheld,
RHODE ISLAND
Rhode Island state withholding is voluntary. If you elect to have state taxes withheld,
SOUTH CAROLINA
South Carolina state withholding is voluntary. If you elect to have state taxes withheld,
select “Voluntary State Income Tax Withholding/ based on my state's tax table formula.”
SOUTH DAKOTA
South Dakota does not have personal income tax. State tax will not be withheld from
any distribution.
TENNESSEE
Tennessee does not have personal income tax. State tax will not be withheld from any
distribution.
TEXAS
Texas does not have personal income tax. State tax will not be withheld from any
distribution.
UTAH
Utah state withholding is voluntary. If you elect to have state taxes withheld, select
“Voluntary State Income Tax Withholding/ based on my state's tax table formula.”
VERMONT
Vermont state tax withholding is mandatory if federal taxes are withheld. If no federal
taxes are withheld, no state taxes will be withheld. State withholding is based on the
amount of federal taxes withheld.
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The amount withheld is 27% of the federal amount withheld.
Periodic payments
VIRGINIA
Virginia state tax withholding is mandatory if federal taxes are withheld. If no federal
Periodic payments
WASHINGTON
Washington does not have personal income tax. State tax will not be withheld from any
distribution.
WEST VIRGINIA
West Virginia state withholding is voluntary. If you elect to have state taxes withheld,
WISCONSIN
Wisconsin state withholding is voluntary. If you elect to have state taxes withheld, select
“Voluntary State Income Tax Withholding” and enter a flat dollar amount. If you select
“Voluntary State Income Tax Withholding” and do not enter a flat dollar amount,
MassMutual will not withhold any state taxes.
WYOMING
Wyoming does not have personal income tax. State tax will not be withheld from any
distribution.
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