A. To be completed by the Participant
EMPLOYEE REQUEST FOR LOAN: I hereby request to borrow from my account balance under the Plan: (I understand that I may not
request a loan, or have an outstanding loan, if my benefit is in pay status.)
$______________________ or, if less is available, the Maximum Amount Available ($1,000 minimum).
The Maximum Amount Available ($1,000 minimum). The Maximum Amount Available is determined on the valuation date on which
the loan proceeds are to be issued from the plan. The Maximum Amount Available is the lesser of 50% of the vested account
balance or $50,000 (reduced by the highest outstanding balance during the last twelve months of all loans made from this Plan).
Loan Fees: I understand and agree that the total loan amount due and payable will include a processing fee of $50 to be deducted
from my account under the Plan in the same manner as the amount borrowed. Additionally, a maintenance fee of $12.50 will be
deducted from my account at the end of each calendar quarter.
Source of Loan Funds: I understand that the proceeds of my Loan and any Loan Fee will be withdrawn from my account under the
Plan against all available investment choices (except a Self Directed Brokerage Account) and from each contribution source on a pro-
rata basis.
Loan Repayment Terms: I agree to repay this loan to my account through payroll deductions within:
1 Year 2 Years 3 Years 4 Years 5 Years
_______ Years (Greater than 5 Years is permitted for the purchase of principal residence only).
Payroll Deduction Authorization: I understand and authorize loan repayments to be made by payroll deduction for each pay period in
which a payment is due in accordance with the terms of the Promissory Note and Loan Agreement, starting with the first applicable pay-
period following the date this loan is entered into or as soon as administratively practicable and continuing until the loan is repaid in full.
I understand that loan repayments will be invested in the investment choices under the Plan in accordance with my most current
investment election on file with the Plan Administrator (except a Self Directed Brokerage Account).
B. To be completed by the Plan Administrator, if applicable
Loan Interest Rate The interest rate will be the Current Plan Loan Interest Rate on file at MassMutual or _____________%
Payroll Frequency Repayments will be made at the frequency on file at MassMutual. If repayments are to be made at another
frequency indicate:
Loan 457-6 PYRL Rev. 3.14
Page 1 of 3
Please make a copy for your records.
Loan Application & Agreement - 457(b)
Overnight Mail Address:
MassMutual Retirement Services
1 Griffin Road North, Windsor, CT 06095-1512
Mail Address:
MassMutual Retirement Services
P.O. Box 1583, Hartford, CT 06144-1583
Group No. Plan Name SSN
Employee Name: Last, First, M.I.
Address: City, State, Zip
Home Phone: Work Phone/ Ext:
Fax to:
877-526-2531 or
Weekly Bi-Weekly Semi-Monthly Monthly
First Payment Date:
Important Note: Please indicate a First Payment Date that is consistent with your firm’s Payroll schedule. Please note that in the event
the Payroll Date you indicate is more than 60 days later than the date of the Authorized Signer’s Signature in Section C authorizing the
loan, this submission will be considered as ‘Not In Good Order’ and will not be processed, unless and until you provide an earlier First
Payment Date. If no date is entered, the loan repayment schedule will reflect that repayments are to begin 14 days from the date the
loan application is received by MassMutual in good order at the address above.
C. Signatures
I understand and agree to the terms of the Loan Agreement as stated on page 3 of this application. I understand that I may fully repay
the outstanding amount of this loan without penalty. Partial prepayments are not allowed. Upon my retirement, death or termination of
employment or termination of the Plan prior to the full repayment of the loan, the outstanding principal amount of the loan (principal and
accrued interest) will be considered due and payable. My vested account balance will be reduced by the amount of outstanding principal
balance of the loan before any distribution to me or my beneficiary, whichever is applicable. I understand and agree that with the loan
proceeds I will receive a Promissory Note. I understand and agree that none of the terms or provisions of this Promissory Note may be
waived, altered, modified or amended except in writing and duly executed by me and the Plan Trustees. I further understand my
endorsement of the check representing this loan shall constitute my agreement to all terms of the Promissory Note and Loan
Agreement. If I return the check to MassMutual unsigned, I authorize MassMutual to deduct a reprocessing fee of $75 from my account
under the Plan.
Employee's Signature Date
Please forward this application to your Plan Administrator for final review and approval.
I approve this loan as shown and certify that the above data in regard to the participant is true and accurate to the best of my knowledge
and, as applicable, that I have considered any other loan made from any other plan of the employer in determining the amount available
to the Participant. I hereby direct MassMutual to issue the loan proceeds accompanied by a Promissory Note to the Participant based
upon the information indicated above. I understand that the loan request will be processed as of the date it is received in good order at
Plan Administrator's Signature Date
Loan 457-6 PYRL Rev. 3.14
Page 2 of 3
Loan Agreement
I agree that the following terms will apply to the Loan issued to me by the Plan.
Effect of Borrowing - Limitations: I agree that the amount borrowed will be advanced from my investment accounts maintained under
the Plan on my behalf in accordance with the Plan provisions. I understand that the maximum Loan amount is limited to the lesser of
50% of my vested account balance under the Plan or $50,000 reduced by the highest outstanding balance on any loan(s) made to me
from this Plan (or any other Plan sponsored by the Employer) during the twelve months period ending on the date this Loan is made.
Effect of Repayment: As I repay this Loan, the repayment (both principal and interest) will be credited to my Plan account and
invested in accordance with the terms of the Plan. I will be provided with a complete repayment schedule for this Loan.
Loan Terms: The basic terms of the Loan are specified in the Promissory Note provided with the loan proceeds. I promise to repay this
Loan in the manner and to the extent required by this Agreement and rules of the Plan Administrator.
Repayment of Loan: During any period I am employed by the Employer, I hereby authorize the Plan Administrator to deduct from my
salary, or amounts paid in lieu thereof, the repayment amounts set forth in the Promissory Note. During any period of time when I am
not receiving salary or amounts paid in lieu thereof (such as certain periods of layoff or leaves of absence) or my salary or other
payment is insufficient to make the required repayment or if I should cancel my salary deduction authorization, I agree to make the
scheduled repayment when due (or any deficiency therein) by check to the Plan Administrator.
Event of Default: If any of the following events occur before this Loan plus interest is repaid in full, there shall be an event of default: (1)
termination of my employment for any reason (including death); (2) a distribution is required to be made under a qualified domestic
relations order affecting my account and the distribution would exceed my interest in the Plan less the outstanding balance (principal
and accrued interest); or (3) my failure to repay the Loan under the terms of the Plan. Upon the event of default, I acknowledge that the
entire balance of the Loan plus any accrued but unpaid interest shall be considered immediately due and payable. I authorize the Plan
Administrator to foreclose on the outstanding Loan by deducting the unpaid Loan balance plus accrued but unpaid interest from my
account, to the extent permitted by law.
Security Interest: I understand that the Loan shall be secured by a lien on my interest in the Plan equal to the value of the outstanding
principal plus interest. Accordingly, I grant a security interest in, and a general lien upon, the vested balance of my Plan account as
security for the payment when due of the principal and interest on the Loan.
Defined Terms : “Plan” means the Eligible Deferred Compensation Plan funded by the investment product administered by MassMutual
identified by the Group No. on this document. “Employer” means the Plan’s sponsor. The term “Loan,” “Plan Administrator,” and
“Trustee(s)” have the meaning given such terms under the Plan.
Loan 457-6 PYRL Rev. 3.14
Page 3 of 3
Terms of the Plan: This Loan Agreement and the Loan being made to me are subject to the terms of the Plan as now in effect or later
amended, including any rules made by the Plan Administrator under the authority of the Plan. The pertinent provisions and defined
terms of the Plan and rules of the Plan Administrator are considered in the terms of this Agreement.
Early and Late Repayment: I have the right to repay at the end of the any month in full (but not in part) the outstanding principal
balance of the Loan plus accrued but unpaid interest to the date of such repayment.
MassMutual Retirement Services (MMRS) is a division of Massachusetts Mutual Life Insurance Company (MassMutual) and its affiliated companies
and sales representatives.
Current MassMutual vested account balance, including any outstanding loan
amount. Note: only include the balance of the account for which the loan is
being requested. We do not aggregate the account balances.
2. Maximum % Limit: Line 1 x 50%.
3. Maximum $ Limit: If there has been no outstanding loan balance for the last 12
months, enter $50,000 on Line 3. Otherwise complete the following calculation
and enter the result from (d) on Line 3.
= Highest outstanding loan balance in the last 12 months. Note:
Provide all highest outstanding loan balances that the participant
has with any provider under your plan (including MassMutual’s).
= Current outstanding loan balance. Note: Provide all
outstanding loan balances that the participant has with any
provider under your plan (including MassMutual’s).
(c) = (a) minus (b). $
(d) = $50,000 minus (c). $
4. Maximum Loan amount: Lesser of Line 2 or Line 3.
5. Current outstanding loan balance.
6. Available Loan Amount: Line 4 minus 5.
If the result is less than zero, enter zero.
Do not return this worksheet to MassMutual.
This worksheet is provided to the Participant and Employer for informational purposes only and is to be used to assist in
the computing of the maximum participant loan amount available.
Do not return this worksheet to MassMutual.
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