Direct Deposit Agreement

Please select all that apply: ____New Enrollment _____Bank Change

____ Address Change _____Account Change

Annuitant’s Information CONTRACT NAME & CONTRACT NUMBER

ANNUITANT ID/SOCIAL SECURITY NUMBER

ANNUITANT NAME

AREA CODE & HOME TELEPHONE

( )

Annuitant’s Permanent Legal Resident Address (for correspondence & tax purposes)

NUMBER AND STREET OR PO BOX

CITY, STATE, ZIP

Bank information (Please verify this information with your bank when filling this out.)

YOUR BANK’S NAME YOUR BANK’S AREA CODE & TELEPHONE

( ) YOUR BANK’S STREET ADDRESS

YOUR BANK’S CITY, STATE, ZIP

Please indicate only one account category below.

YOUR CHECKING ACCOUNT NUMBER (ATTACH VOIDED CHECK) OR

SAVINGS ACCOUNT NUMBER

YOUR BANK’S 9-DIGIT ROUTING NUMBER

Copyright © <year>Massachusetts Mutual Life Insurance Company, Springfield, MA 01111. All rights reserved. www.massmutual.comMassMutual Financial Group is the fleet name for Massachusetts Mutual Life Insurance Company

(MassMutual) [of which Retirement Services is a division] and its affiliated companies and sales representatives. RS-30636-00

ANNUITANT’S SIGNATURE: DATE:

I hereby authorize MassMutual to make all pension payments due to me under the above

numbered contract by Electronic Direct Deposit to the bank account designated above. I

also authorize MassMutual to initiate debits to the bank account for overpayments made to

me and the bank named above to debit my account and refund any such overpayments to

MassMutual. Payments made under this agreement shall fully satisfy MassMutual’s

obligation to make payments to me.

I also agree that to cancel this agreement, I must give at least one month’s written notice to

the MassMutual Home Office. Upon my death, my executors or administrators shall pay to

MassMutual from my estate the amount of any payments collected by the Bank which were

not payable because they were issued after my death.