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Source of Loan Funds: I understand that the proceeds of my Loan and any Loan Fee will be withdrawn from my account under the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-
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
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
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:
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.