LifeTrust Variable Annuity 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 Dispa tch 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) Joint Owner Name (if applicable) 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(s) are 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 Pa yment Tax payments. Amount: $ Year: Changing allocations will not affect funds currently held If the contribution is a rollover, indicate date the rollover in the investment choices. If you wish to transfer funds among the investment choices use form F6551, 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(s) are required below for allocation changes. ______% Invesco V.I. Capital Appreciation 1 (017/047) ______% MML Blend (013/043) ______% Invesco V.I. Discovery Mid Cap Growth 2 (015/045) ______% MML Equity (010/040) ______% Invesco V.I. Global 3 (016/046) ______% MML Managed Bond (012/042) ______% Invesco V.I. Global Strategic Income 4 (018/048) ______% MML U.S. Government Money Market (011/041) ______% Invesco V.I. U.S. Government Money Portfolio 5 (021/051) ______% 5 Year Fixed Account (105) ______% Invesco V.I. Main Street 6 (022/052) ______% 7 Year Fixed Account (107) 7 ______% Invesco V.I. Main Street Small Cap (023/053) 100% Total 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. Global Strategic Income Fund. 5 Formerly known as Invesco Oppenheimer V.I. Government Money Fund. 6 Formerly known as Invesco Oppenheimer V.I. Main Street Fund®. 7 Formerly known as Invesco Oppenheimer V.I. Main Street Small Cap Fund®. III. Signature(s) Signature(s) are required for allocation changes. ________________________________ ________________________________ ______________ Print Owner Name Owner Signature Date ________________________________ ________________________________ ______________ Print Joint Owner Name (if applicable) Joint Owner Signature (if applicable) Date Massachusetts Mutual Life Insurance Company (MassMutual), 1295 State Street, Springfield, MA 01111-0001 and its subsidiaries: C.M. Life Insurance C ompany and MML Bay State Life Insurance Company, 100 Bright Meadow Boulevard, Enfield, Connecticut 06082-1981. F9298 0521 .