Panorama Additional Payment Remittance

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Panorama Additional Payment Remittance Ma ssMutual Overnight Address: Annuity Payment Services Ma ssMutual PO Box 74908 Annuity Payment Services Chicago, IL 60675-4908 8th Floor-Suite 4908 Questions: (800) 272-2216 Receipt and Dispatch Email Address: 350 North Orleans Street [email protected] Chicago, IL 60654 Use this form to submit an additional payment for IRA and Non-Qualified contracts only. I. Owner/Annuitant Information Contract Number Annuitant Date Owner Name (Please Print) II. Remittance Please complete and return the entire form with your payment To change investment allocations, use whole numbers only. to the address above. Make the check payable to MassMutual. Allocations must add up to 100%. Signature is required If this is an IRA contribution, please indicate the tax year. If a below for allocation changes. tax year is not specified at the time of remittance, MassMutual will default to the current year. Contact your tax advisor Change investment allocations for this payment only. regarding contribution limits. Change investment allocations for this and all future payments. Payment Tax Amount: $ Year: Changing allocations will not affect funds currently held in the investment choices. If you wish to transfer funds If the contribution is a rollover, indicate date the rollover among the investment choices use form F6450, call the distribution was received by the applicant from the financial Service Center or visit our Web site at institution: _______________________ www.massmutual.com/asc. If no allocations are selected, the payment will be invested based on existing allocations. Certain investment choices may not be available in all states. Signature is required below for allocation changes. Invesco V.I. Ca pital Appreciation 1 (96) % Invesco V.I. Discovery Mid Cap Growth 2 (97) % Invesco V.I. Global 3 (98) % Invesco V.I. U.S. Government Money Portfolio 4 (089) % MML Equity Index (93) % MML High Yield (76) % MML Ma naged Bond (112) % MML NASDAQ-100® (94) % MML Oppenheimer Small Cap Equity (95) % MML Short-Du rat ion Bond (75) % MML Small Ca p Index (100) % Panorama Growth (091) % Panorama Total Return (092) % Total 100 % 1 Formerly known as Invesco Oppenheimer V.I. Capital Appreciation Fund. 2 Formerly known as Invesco Oppenheimer V.I. Discovery Mid Cap Growth Fund. 3 Formerly known as Invesco Oppenheimer V.I. Global Fund. 4 Formerly known as Invesco Oppenheimer V.I. Government Money Fund. III. Signature Signature is required for allocation changes. _______________________________ __________________________________ _______________ Print Owner Name Owner Signature Date Massachusetts Mutual Life Insurance Company (MassMutual), 1295 State Street, Springfield, MA 01111-0001 and its subsidiaries: C.M. Life Insurance Company and MML Bay State Life Insurance Company, 100 Bright Meadow Boulevard, Enfield, Connecticut 06082-1981. F9304 0521 .

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