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f6809roth COMPLETE ALL PAGES MassMutual, PO Box 219062, Kansas City MO 64121-9062

For Overnight Mail: MassMutual, 430 W 7th St, Kansas City MO 64105

PLAN NAME PARTICIPANT INFORMATION CHANGE

Account Number _____________________

Section 1: Complete this section: Name ___________________________ __________________ _______________________________ first middle last Social Security No. ___________________ Address _______________________________________________________________________ street

_______________________________________________________________________ city state zip Telephone # ________________________ Email Address __________________________________ Please check box if the address, telephone # or email address listed above is a change request.

For your mailing address, provide either a street address or P.O. Box, not both. If you provide both, MassMutual will follow USPS Guidelines and use the P.O. Box as your mailing address. Please work with the plan sponsor to provide the necessary information to request the change below.

MARITAL STATUS CHANGE: Change to Married Not Married or Legally Separated PARTICIPANT NAME CHANGE:

Name changed from: ________________________ _________________ ________________________

first middle last Name changed to: ________________________ _________________ ________________________

first middle last PARTICIPANT SOCIAL SECURITY NUMBER CHANGE: An IRS Form W-9 has been provided

to the Plan Administrator or Plan representative.

Social Security Number changed from: ________________________

Social Security Number changed to: ________________________ BIRTH DATE CORRECTION: My date of birth is: _________________

mm/dd/yyyy PAYROLL FREQUENCY CHANGE: I authorize the reamortization of any outstanding participant loans.

The new payroll frequency is monthly (12/year) semi-monthly (24/year) biweekly (26/year) weekly (52/year)

CHANGE(S) • For investment selection changes, transfers between investments, or address changes call 1-800-743-5274 or

access our participant website at www.retiresmart.com.

Section 2: Check the boxes for ALL changes requested and provide applicable information:

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For Overnight Mail: MassMutual, 430 W 7th St, Kansas City MO 64105

PAYROLL DEDUCTION CHANGE: I authorize this election to supersede any prior election, and I understand I may revoke this election at any time or change this election as allowed by the Plan by completing a new Participant Information Change form.

Before-Tax Contribution: _____% from my compensation each pay period for deposit to my account (not to exceed applicable Plan or regulatory limits)

After-Tax Contribution: _____% from my compensation each pay period for deposit to my account (not to exceed applicable Plan or regulatory limits)

Roth Contribution: _____% from my compensation each pay period for deposit to my account (not to exceed applicable Plan or regulatory limits)

I elect to make no contributions (0%) to the Plan at this time.

The Plan may also limit the combined totals of Before-Tax, After-Tax, and Roth contributions. Please refer to your Summary Plan Description for further details regarding Plan limits.

BENEFICIARY CHANGE: This designation supersedes any prior designation.

IMPORTANT: The purpose of this Beneficiary Election is to collect the information necessary for the Plan Administration to identify your intended beneficiary upon your death. If the beneficiary information is missing, incomplete, or if your intended beneficiary cannot otherwise be determined, the beneficiary of your account balance upon your death will be determined by the plan fiduciary/Plan Administrator pursuant to the plan documents and applicable law. Consequently, if the information required by your Plan Administrator to properly identify your intended beneficiary is not provided below, there is a risk that your account balance will not be distributed as you intend.

Primary Beneficiary: (Check either box 1 or 2)

1. Spouse Primary Beneficiary: I designate my spouse to receive my entire account balance upon my death. Spouse's Name: _________________________________________________________________________ Spouse’s Social Security Number: ___________________ Spouse’s Date of Birth: __________________ mm/dd/yyyy

Spouse’s Address _________________________________________________________________________ street

_________________________________________________________________________ city state zip

2. Non-Spouse or Multiple Primary Beneficiaries: I designate the following person(s) to receive my account balance upon my death: [Up to 3 decimals may be entered when assigning percentages (e.g., 33.333%, 33.334%, etc.), but the total for all primary beneficiaries must equal 100%.]

Name Relationship Social Security #

Street Address Date of Birth

City, State, Zip Percent

Name Relationship Social Security #

Street Address Date of Birth

City, State, Zip Percent

Name Relationship Social Security #

Street Address Date of Birth

City, State, Zip Percent

f6809roth COMPLETE ALL PAGES MassMutual, PO Box 219062, Kansas City MO 64121-9062

For Overnight Mail: MassMutual, 430 W 7th St, Kansas City MO 64105

Name Relationship Social Security #

Street Address Date of Birth

City, State, Zip Percent

(must total 100%)

If you are married and you have not designated your spouse as primary beneficiary, please have your spouse provide consent below. SPOUSAL CONSENT: I understand I have a legal right to a death benefit equal to the participant's entire account balance. I understand that I can waive that legal right, and allow my spouse to designate a beneficiary other than myself. It is my intent, by signing below, to limit my consent only to the specific beneficiary named above, and any future non-spouse beneficiary election will require my consent I further understand and acknowledge that if I sign this form to consent to the beneficiary election above, no death benefit will be payable to me. _______________________________________________ _______/_______/_______ Spouse's Signature Date

The spouse’s signature must be witnessed by the Plan Administrator or a Notary Public:

Plan Administrator: Plan Administrator Signature Date -OR-

Notary Public: Notarization of spousal consent can be signed off by a Notary Public or the Plan Administrator. A Notary Seal is not required when signed by the Plan Administrator or when participant resides in one of the following states: CT, KY, LA, ME, MI, NJ, NY, RI, VT

Before me, the undersigned notary, personally appeared _______________________________, and proved to me through identification documents allowed by law, which were ________________, to be the person who signed the preceding document in my presence and who affirmed to me that they executed the above Consent of Spouse as a free and voluntary act.

IN WITNESS WHEREOF, I have signed my name and affixed my official notarial seal this ____ day of ________________, ________

Witnessed: ______________________________ State: _____________ County: ______________ (official signature and seal of notary) My Commission expires: _________________ Contingent Beneficiary (optional): If no Primary Beneficiary listed above is alive upon my death, I designate the following person(s) to receive my account balance upon my death: [Up to 3 decimals may be entered when assigning percentages (e.g., 33.333%, 33.334%, etc.), but the total for all contingent beneficiaries must equal 100%.]

Name Relationship Social Security #

Street Address Date of Birth

City, State, Zip Percent

Name Relationship Social Security #

Street Address Date of Birth

City, State, Zip Percent

Name Relationship Social Security #

Street Address Date of Birth

City, State, Zip Percent

f6809roth COMPLETE ALL PAGES MassMutual, PO Box 219062, Kansas City MO 64121-9062

For Overnight Mail: MassMutual, 430 W 7th St, Kansas City MO 64105

Name Relationship Social Security #

Street Address Date of Birth

City, State, Zip Percent

(must total 100%) NOTE: An electronic copy of this form is kept on record. Plan Administrator: Please retain a copy of this form in your files. Sample wording for use in completing this part of the form:

To Designate Use This Wording

1. Your estate Executors or Administrators of my estate

2. The trustee of the Trust (Name of trustee) as trustee, or the then acting trustee, of the established under your Will Trust established under (your name) Will dated (date of Will)

3. The trustee of your Revocable (Name of trustee) as trustee, or the then acting trustee, of the or Irrevocable Trust (name of Trust) established on (date of Trust) Trust as Beneficiary (certification needed to apply “look-through” treatment):

Before designating a trust as the beneficiary of your plan benefit, you should consult an attorney with expertise in trusts and estates law.

Generally, only individuals can be named as a designated beneficiary of an IRA or qualified retirement plan. However, if a trust that is named as the beneficiary of a participant's retirement plan meets all of the following regulatory requirements (see Treas. Reg. section 1.401(a)(9)-4, A-5), then the trust is a “qualified look-through trust,” and the beneficiaries of the trust can qualify as the designated beneficiaries of a participant's IRA or qualified retirement plan:

1. Trust is a valid trust under state law, or would be but for the fact that there is no corpus. 2. The trust is irrevocable or will, by its terms, become irrevocable upon the death of the employee. 3. The beneficiaries of the trust who are beneficiaries with respect to the trust's interest in the employee's benefit are

identifiable from the trust instrument. 4. The plan administrator has been provided with the relevant trust documentation by October 31 of the year following the

year of the participant's death.

SIGNATURES _______________________________________________ _______/_______/_______ Participant Date I, the plan administrator, certify, to the best of my knowledge, the above information is correct. _______________________________________________ _______/_______/_______ Plan Administrator Date

RS-47885-00 ©2019 Massachusetts Mutual Life Insurance Company (MassMutual®) Springfield, MA. 01111-0001. All rights reserved. www.MassMutual.com.