IRA, Roth IRA & SEP IRA Application

Transcription

1 IRA, Roth IRA & SEP IRA Application Prudential Mutual Fund Services LLC (PMFS), a Prudential Financial company For assistance: Financial professionals: (888) Clients: (800) Instructions Please print clearly, preferably in capital letters and black ink. Return completed application to Prudential Mutual Fund Services LLC. See page 10 for complete mailing instructions. USA Patriot Act requirements To help the government fight the funding of terrorism and money laundering activities, Prudential Financial is required to obtain, verify, and record information on each person who opens an account. Please be sure to review the Privacy Policy at the end of this application. FATCA reporting - The Foreign Account Tax Compliance Act (FATCA) requires a participating foreign financial institution to report all United States account holders that are specified United States persons. Important The following information is required for each person associated with the account: Name Residence address Date of birth Taxpayer ID number (SSN or EIN) 1 If this information is not provided, we will be unable to open the account. If we are unable to verify your identity, Prudential Financial reserves the right to close your account or take other steps we deem reasonable. Account Ownership All information is required. If a minor IRA account is being setup, then please provide the information of the custodian/guardian, in the same format, on a separate sheet. First name MI Last name Social Security number Date of birth Account mailing address City State ZIP code 4-digit ext. Residential/Permanent address (Complete if different from above or PO Box was provided for account mailing address.) City State ZIP code 4-digit ext. Daytime phone number Extension Cell phone number address (optional) Citizenship U.S. Citizen Resident alien Nonresident alien* Country of residence * Nonresident aliens must attach the applicable Internal Revenue Service (IRS) Form W-8(BEN, ECI, EXP, IMY), which can be obtained at Marital Status Married Single Widowed Divorced Number of Dependents MF1011 Ed. 1/2018 Page 1 of 11

2 2 Choose your Beneficiaries Tell us who should receive your account balance after your death. For each beneficiary you list by name, check a beneficiary type (primary or secondary) and provide all information. If the Per Stirpes designation is checked and the named beneficiary does not survive the account owner, but leaves surviving descendants, then any share otherwise payable to such beneficiary shall instead be paid to such beneficiary s surviving descendants, by right of representation. Please note, the primary and secondary beneficiary totals must each equal 100%. Spousal Consent If you are a married person and have not designated your spouse as your sole primary beneficiary, your spouse must sign section 13. A. Primary Beneficiaries (check all that apply) Primary Secondary (Please check one) Name: Per Stirpes Percentage: Social Security Number: Date of Birth: Relationship: % Address: Daytime phone number: City: State: Zip Code: 4-digit ext address Primary Secondary (Please check one) Name: Per Stirpes Percentage: Social Security Number: Date of Birth: Relationship: % Address: Daytime phone number: City: State: Zip Code: 4-digit ext address MF1011 Ed. 1/2018 Page 2 of 11

3 2 Beneficiaries (continued) Primary Secondary (Please check one) Name: Per Stirpes Percentage: Social Security Number: Date of Birth: Relationship: % Address: Daytime phone number: City: State: Zip Code: 4-digit ext address Primary Secondary (Please check one) Name: Per Stirpes Percentage: Social Security Number: Date of Birth: Relationship: % Address: Daytime phone number: City: State: Zip Code: 4-digit ext address Please check here if you have attached a separate sheet with additional beneficiary designations. Include the date and your signature. Minor Beneficiaries (optional) If any beneficiary named in this form is a minor, I hereby request that proceeds be paid to as custodian under the (name of state) UTMA (to the extent permitted by named state). Important: The date of birth of the named minor is required in Section 2 (Individuals) for this designation to apply. MF1011 Ed. 1/2018 Page 3 of 11

4 3 Account Type & Contribution Information A. Account Type (Choose only one.) Traditional IRA Rollover IRA Roth IRA*(Establishment date) SEP IRA**(Employer name) * The establishment date is the earliest date you either opened a Roth IRA or originally converted from a traditional IRA to a Roth IRA. If you do not provide this information we will use the date the account is established as the establishment date. This information is requested by the IRS and is needed to determine compliance with the taxable five-year holding period requirement. ** For SEP IRAs, the tax year for employer contributions is for your informational purposes only; all employer contributions are reported in the year received by Prudential Mutual Fund Services LLC (PMFS). B. Inherited IRA Decedent s First name MI Last name Decedent s Date of death Note: Please complete and attach the Beneficiary Distribution Form (IRA) (MF1024) to establish required minimum distributions (RMD) from your new inherited IRA. C. Contribution/Purchase Instructions Contributions (For SEP IRAs, input employee contributions as a Contribution.) Contribution for tax year 2 0 Regular $ Catch-up $ Contribution for tax year 2 0 Regular $ Catch-up $ Employer contribution for tax year 2 0 Amount $ (SEP IRA only) Employer contribution for tax year 2 0 Amount $ (SEP IRA only) Rollover Purchase. Within 60 days of your receipt either from another like IRA (e.g. Roth IRA to Roth IRA or Traditional IRA to Traditional IRA) or an eligible rollover distribution from a retirement plan to a Traditional IRA, Rollover IRA or Roth IRA. Rollover check amount $ Direct Rollover from an employer-sponsored retirement plan. Complete the Transfer/Direct Rollover/Conversion Authorization form (MF1012). Estimated amount $ Direct Rollover from a Roth 401(k) plan or Roth 403(b) plan. Complete the Transfer/Direct Rollover/Conversion Authorization form (MF1012). Transfer of an existing IRA, Roth IRA, SEP IRA, or SARSEP account from another custodian. Complete the Transfer/Direct Rollover/Conversion Authorization form (MF1012). Conversion from an existing Traditional IRA, SEP IRA, or SARSEP IRA account from another custodian into a Roth IRA. Complete the Transfer/Direct Rollover/Conversion Authorization form (MF1012). Estimated amount $ Estimated amount $ Estimated amount $ Please make check payable to Prudential Mutual Fund Services. MF1011 Ed. 1/2018 Page 4 of 11

5 4 Mutual Fund Selection & Allocation Please provide your investment selections by checking the box next to the fund number and indicate allocations as either a percentage (%) or dollar amount ($). If a fund offers a share class not listed, then write the fund number or share class in the Other column next to the fund name. Refer to the fund s prospectus for fund minimum and eligibility requirements. ASSET ALLOCA TION FUNDS EQUITY FUNDS MF1011 Ed. 1/2018 Page 5 of 11 Fund Share Class Initial Investment Fund Name Class A Other % $ Asset Allocation Prudential Balanced Fund 296 Prudential Conservative Allocation Fund 1509 Prudential Growth Allocation Fund 1501 Prudential Moderate Allocation Fund 1505 Prudential QMA Global Tactical Allocation Fund 1132 Equity Prudential Jennison 20/20 Focus Fund 515 Prudential Jennison Blend Fund 21 Prudential Jennison Diversified Growth Fund 560 Prudential Jennison Equity Income Fund 1760 Prudential Jennison Equity Opportunity Fund 285 Prudential Jennison Focused Growth Fund 576 Prudential Jennison Growth Fund 267 Prudential Jennison Mid Cap Growth Fund 298 Prudential Jennison Rising Dividend Fund 1101 Prudential Jennison Small Company Fund 25 Prudential Jennison Value Fund 26 Prudential QMA Large-Cap Core Equity Fund 533 Prudential QMA Mid-Cap Value Fund 1756 Prudential QMA Small-Cap Value Fund 1100 Prudential QMA Stock Index Fund 573 Prudential QMA Strategic Value Fund 586 Prudential QMA Defensive Equity Fund 527 Specialty Prudential Global Real Estate Fund 511 Prudential Income Builder Fund 525 Prudential Jennison Financial Services Fund 546 Prudential Jennison Global Infrastructure Fund 1090 Prudential Jennison MLP Fund 1093 Prudential Jennison Natural Resources Fund 32 Prudential Jennison Utility Fund 9 Prudential QMA Large-Cap Core Equity PLUS Fund 1191 Prudential QMA Long-Short Equity Fund 1104 Prudential Real Assets Fund 1050 Prudential Real Estate Income Fund 1140 Prudential Select Real Estate Fund 1110 Prudential US Real Estate Fund 1030 (continued)

6 4 Mutual Fund Selection & Allocation (continued) EQUITY FUNDS FIXED INCOME FUNDS Target Date FUNDS Global/ International Equity Taxable Fixed Income Tax Exempt Money Market Day One Funds MF1011 Ed. 1/2018 Page 6 of 11 Fund Share Class Initial Investment Fund Name Class A Other % $ Prudential QMA International Equity Fund 574 Prudential Jennison Emerging Markets Equity Fund 1114 Prudential Jennison Global Opportunities Fund 1037 Prudential Jennison Intl Opportunities Fund 1083 Prudential Absolute Return Bond Fund 1044 Prudential Core Bond Fund 1128 Prudential Corporate Bond Fund 1136 Prudential Emerging Mkts Debt Hard Currency Fund 2100 Prudential Emerging Mkts Debt Local Currency Fund 1054 Prudential Floating Rate Income Fund 1034 Prudential Global Absolute Return Bond Fund 1146 Prudential Global Total Return Fund 272 Prudential Global Total Return USD Hedged Fund 2104 Prudential Government Income Fund 84 Prudential High Yield Fund 87 Prudential International Bond Fund 1167 Prudential Short Duration High Yield Income Fund 1086 Prudential Short Duration Multi-Sector Bond Fund 1096 Prudential Short-Term Corporate Bond Fund 78 Prudential Total Return Bond Fund 264 Prudential Unconstrained Bond Fund 1143 Prudential California Muni Income Fund 6 Prudential Muni High Income Fund 28 Prudential National Muni Fund 22 % $ Prudential Short Duration Muni High Income Fund 1107 Prudential Government Money Market Fund % $ Day One Funds Class R2 Prudential Day One Income Fund 4001 % $ Prudential Day One 2010 Fund 4007 % $ Prudential Day One 2015 Fund 4013 % $ Prudential Day One 2020 Fund 4019 % $ Prudential Day One 2025 Fund 4025 % $ Prudential Day One 2030 Fund 4031 % $ Prudential Day One 2035 Fund 4037 % $ Prudential Day One 2040 Fund 4043 % $ Prudential Day One 2045 Fund 4049 % $ Prudential Day One 2050 Fund 4055 % $ Prudential Day One 2055 Fund 4061 % $ Prudential Day One 2060 Fund 4067 % $ Total: (100% or $) Note: The total must equal 100% or the total dollar amount provided in section 3.

7 5 Letter of Intent & Rights of Accumulation Letter of Intent (LOI): Check here if establishing, complete the Letter of Intent form (MF230 PMFS), and include with this application. Financial professionals can request a copy by calling (888) Rights of Accumulation: Check here and list account numbers below if you qualify for sales discounts on Class A shares. Please refer to the fund s prospectus and Statement of Additional Information to learn more about accounts that may be eligible. Indicate eligible accounts below. Account Number Account Owner Name (first name, MI, last name) Relationship to You 6 Distribution Options All dividends and capital gains will be reinvested if you do not make an election. Dividends Reinvest in shares Pay in cash* Send by ACH to the bank specified in section 9. Capital Gains Reinvest in shares Pay in cash* Send by ACH to the bank specified in section 9. * If the dividends and capital gains are to be distributed in cash or sent by ACH, please complete, sign and return IRS Form W-4P with this application. 7 Telephone/Online Exchange and Redemption Option Your account will automatically be coded with the Telephone/Online Redemption and the Telephone/Online Exchange Privileges, unless you check the No box below. I do not want telephone exchange and redemption privileges. Unless otherwise indicated above, you authorize the Fund s distributor, Prudential Investment Management Services LLC (PIMS), to accept telephone exchange and redemption instructions from any person identifying himself/herself as the owner of the account or as the owner s dealer representative conveying instructions of the owner. PIMS and/or the Fund s transfer agent, Prudential Mutual Fund Services LLC (PMFS), will employ reasonable procedures to confirm that such telephone instructions are genuine. Neither the Funds, PIMS nor PMFS shall be liable for any losses due to unauthorized or fraudulent instructions provided that such procedures are followed. Telephone exchanges and redemptions are subject to the procedures and conditions set forth in each Fund s prospectus. MF1011 Ed. 1/2018 Page 7 of 11

8 8 Purchase Options (Check all that apply.) A. ACH Purchase Option: Check if you want the capability to make wire purchases, online or by telephone, upon demand, by having the purchase amount debited from your bank account. B. Automatic Investment Plan (AIP): Set up recurring purchases into a fund and have the purchase amount debited from your bank account. Note: All contributions will be processed as current year contributions and the total contributions may not exceed the maximum allowed per tax year. Frequency (The minimum investment amount is $50 per fund.): Weekly on (enter day of week e.g. Monday) Monthly on the (enter a day of the month e.g. 15th) Start date* *If a specific day of the month is not listed above, debits will be made on or about the 15th of the month. Share class $ into the Fund A C $ into the Fund A C $ into the Fund A C $ into the Fund A C $ into the Fund A C $ into the Fund A C $ Total amount (to be debited from bank/credit union account as specified in section 9) Other 9 Bank of Record* (Complete only if section 8 is completed.) Bank/Credit union name Bank telephone number Bank routing number Bank account number *To ensure accuracy, verify with your bank or credit union. Name of depositor on bank records (first, middle initial, last name) Bank type: Checking Savings Name of joint depositor on bank records (first, middle initial, last name) Attach voided check here. Ü Ü Name on bank account Check no Street address City, State ZIP DATE PAY TO THE ORDER OF $ DOLLARS FOR Ý ABA number (9 digits) ÝBank account number MF1011 Ed. 1/2018 Page 8 of 11

9 10 e-delivery and Mailing Preferences* Consider our e-delivery service as your preferred delivery option. It is a fast, easy, and secure way to get account information at any time. It is environmentally friendly by reducing paper and ink use. If you elect e-delivery, you will receive an informing you when your account documents become available and instructions on how to view them online. Note: Certain entity and institutional accounts are not eligible for e-delivery. FEE WAIVER By selecting the three e-delivery options marked with asterisk (*) below and completing the enrollment in e-delivery, your account will qualify for a waiver of the $15 account maintenance fee that is assessed annually on each fund balance under $10,000. Document Type Delivery Preference Prospectuses, Shareholder Reports, and Proxy Mailings e-delivery* U.S. mail Quarterly Statements e-delivery* U.S. mail Year-End Statements and Privacy Notice e-delivery U.S. mail Confirmations e-delivery* U.S. mail Tax Forms After account setup, log in online to elect the tax form e-delivery option. address for e-delivery required only if e-delivery is selected above. By enrolling for e-delivery, you consent to receive electronic versions instead of paper copies of materials for your mutual fund accounts. Once your account is established, visit to enroll your account online. PMFS will only use your address to provide you with the material you requested or to send important news about your account. Note: All documents will be sent to you by U.S. Mail if you do not select a delivery preference. 11 Financial Text Message Professional(s) alert for financial Identification transactions and Signature(s) on your account (if applicable) If you would like to receive a text (SMS) message when a financial transaction takes place on your account, please check the box below. We will use the cell phone number in section 1 to send you a text message to confirm your financial transactions (purchases, exchanges and redemptions). Please read our alert user agreement below. Yes, I wish to receive text messages regarding financial transactions processed on my account. You are agreeing to receive periodic service alerts from Prudential, each of which may be delivered to your phone using an automated system. Message frequency may vary. Standard Message and Data Rates may apply to any SMS or MMS you send or receive as part of this program. At any time, you may reply to a text with STOP to cancel future notifications. Terms and Privacy Policy at MF1011 Ed. 1/2018 Page 9 of 11

10 12 Financial Professional(s) Identification and Signature(s) (if applicable) Broker/dealer name (Please print.) Address City State ZIP code 4-digit ext. Broker/dealer number Branch number Representative number* *If more than one rep, use your joint rep number. 1. Financial professional (first name, MI, last name) (Please print.) Financial professional s signature X Branch telephone number Ext. Financial Professional telephone number Ext. 2. Financial professional* (first name, MI, last name) (Please print.) Financial professional s signature X Branch telephone number Ext. Check here if you are a fee-based consultant. Financial Professional telephone number Ext. 13 Spousal Consent Authorization Special laws apply to the designation of a beneficiary by a married person residing in a community property state. Community property is recognized in AZ, CA, ID, LA, NV, NM, TX, WA, WI and Puerto Rico. If you are married and reside in a community property state and have not designated your spouse as your sole primary beneficiary, your spouse must sign this section. Your spouse s signature represents consent to the beneficiary designation. For Federal tax purposes, the term spouse includes any married individuals (same sex or otherwise), if the individuals are lawfully married under state law. Federal law does not recognize domestic partnerships or civil unions that are not designed as married under state law. There are numerous situations that may affect your beneficiary designation. We suggest you consult an advisor who understands both tax-law and related estate-planning implications of this form. Neither Prudential Mutual Fund Services, LLC nor Prudential Investments, or its affiliates will be liable for any consequences resulting from failure to provide proper spousal consent. First name MI Last name Sign here Signature of spouse X (of IRA owner) Date MF1011 Ed. 1/2018 Page 10 of 11

11 14 Signature and Tax Certification The undersigned warrants that I have full authority and I am of legal age to purchase shares pursuant to this application. Further, I acknowledge receipt of the prospectus(es) for the mutual fund(s) which I have selected, and agree to its/their terms. I acknowledge receipt of the applicable Individual Retirement Custodial Account Agreement and Disclosure Statement and I understand that there may be fees associated with this account. I understand this Agreement contains a pre-dispute arbitration clause. By signing below I agree to be bound by these provisions I consent to the householded delivery of any mutual fund prospectuses, shareholder reports, or proxy statements. This means Prudential Mutual Fund Services LLC (PMFS) will deliver a single copy of these documents to shareholders who share an address, even if the accounts are registered in different names. My participation in this program will continue indefinitely unless I contact PMFS. According to Federal law and/or state regulations, your account(s) may be subject to escheatment to your state of residency. Escheatment may be based on account inactivity and/or mail being returned by the post office (RPO). Check with your state Controller s office for additional guidance. Under penalties of perjury, I certify that (cross out any item that is not true): (1) The number shown on this form is my correct Social Security/Tax ID number, (2) I am not subject to backup withholding due to failure to report interest or dividend income, (3) I am a U.S. citizen or other U.S. person (including a U.S. resident alien), and (4) I am not subject to FATCA reporting If you crossed out item 3 above, please indicate country of citizenship and attach applicable Internal Revenue Service Form W-8(BEN,BEN-E,EXP, ECI,IMY). To help the government fight the funding of terrorism and money laundering activities, Prudential Financial is required to obtain, verify, and record information on each person who opens an account. This verification process will take place as we open your account. Once verification is completed, Prudential Financial will be able to fully service and maintain the account. Account Restriction: Check here if you would like PMFS to establish a restricted account from which funds shall be disbursed only upon receipt of a valid court order or other document(s), as appropriate. A copy of the restriction (court order or otherwise), signed and dated on has been provided with this mutual fund application. The restriction shall continue until PMFS receives a valid court order or other written instruction as directed by PMFS, expressly authorizing the removal of the restriction. The Internal Revenue Service does not require your consent to any provision of this document other than the certification required to avoid backup withholding. Sign here Owner s signature X Date Mailing Instructions for Mutual Fund Account Application Standard Prudential Mutual Fund Services LLC mail to: PO Box 9658 Providence, RI Overnight mail to: Prudential Mutual Fund Services LLC 4400 Computer Drive Westborough, MA MF1011 Ed. 1/2018 Page 11 of 11

12 Individual Retirement Accounts Premature Distribution Penalties With some exceptions, monies distributed from your IRA prior to age 59 ½ will be taxed as ordinary income and be subject to a 10 percent early withdrawal penalty. For more details, see the applicable Distributions section(s) of the Custodial Account Agreement and Disclosure Statement. IRA Fees The Prudential Trust Company, the custodian for your IRA, reserves the right to change it fee schedule from time to time without prior notification. Annual Maintenance Fee The annual maintenance fee is $15 per fund, with a $25 maximum for two or more funds. NO FEE will be charged if the value of your IRAs and/or SEP IRAs totals $50,000 or more. Account values are determined on the day of the systematic deduction of the fee, which usually occurs in December of each year.

13 Prudential Mutual Fund Services LLC a Prudential Financial company Transfer/Direct Rollover/ Conversion Form (Qualified Accounts Only) For assistance: Clients: (800) Financial Professionals: (888) Pruco Financial Professionals: (800) What to do to submit your Transfer of Asset request: 1. Decide You can use this form to request these types of transfers: Transfer of Assets If you want to liquidate and transfer the account proceeds from another custodian to PMFS, complete section 3 and the other sections that apply to your request. Transfer-in-Kind If you want to transfer existing Prudential mutual funds and change the custodian to Prudential Trust Company, complete section 4 and the other sections that apply to your request. 2. Complete Read the attached instructions carefully before completing this form. Please provide all requested information in each section to ensure your request is processed in a timely manner. 3. Return Send us your completed form. Return form to: Regular mail Prudential Mutual Fund Services LLC P.O. Box 9658 Providence, RI Express mail Prudential Mutual Fund Services LLC 4400 Computer Drive Westborough, MA 01581

14 1. About You (Please attach only one account type.) If this is for a new Prudential account, you can leave the account number field below blank. PMFS account number Social Security number First name Middle initial Last name Entity name (if applicable) Street Address City State ZIP Code Home phone Mobile phone address 2. About the Account You are Transferring to PMFS A. Account types being transferred to PMFS Traditional IRA Roth IRA SEP-IRA 403(b) Plan Governmental 457 Plan Roth 401(k) Plan SIMPLE IRA Inherited IRA Employer-Sponsored 401(a) Retirement Plan (i.e., 401(k), pension or profit sharing plan, or defined benefit plan) B. Resigning Custodian Information Name of institution/employer-sponsored retirement plan Attention Street address City State ZIP Code Contact name C. Account number(s) to be transferred Contact phone Account number Account number Account number MF1012 Ed. 6/2017 page 1 of 7

15 3. Transfer of Assets All liquidations are done immediately unless special instructions are provided below. A. Liquidate All $ (estimated value) Partial % or $ B. Special instructions for CDs and certain annuity contracts Transfer immediately. I am aware of and acknowledge any penalty I may incur from an early withdrawal. Transfer at maturity (month, day, year): / / (Please submit 4 weeks prior to maturity date.) 4. Transfer-in-Kind Complete this section only if you have existing Prudential mutual funds and want to change your current Trustee/ Custodian. Transfer my funds in kind immediately. All Partial $ 5. PMFS Account Type The transferred proceeds will be invested into the following account type. Traditional IRA, Rollover IRA, or SEP IRA Roth IRA or Roth Conversion IRA Establishment date* Inherited IRA 403(b) Plan You must have an existing account at PMFS. New accounts will not be accepted. * The date you originally contributed to a Roth IRA or converted from a traditional IRA to a Roth IRA. This information is required by the IRS for compliance with the 5 tax-year holding period requirement. MF1012 Ed. 6/2017 page 2 of 7

16 6. Mutual Fund Selection and Allocation I am opening a new account and have attached a completed application. Allocation instructions are included in section 4 of my new account application. For this transfer request, invest the amount received into my existing account(s) (indicated in section 1) in the funds and allocations listed below. Note: All allocations by percentage must total 100%. Fund Name Fund Number Share Class Percent or Amount 7. Tax Withholding Election and Roth Conversion Disclosure Indicate what percentage, if any, we should withhold for federal and state income tax purposes. If you do not want taxes withheld, proceed to the next section. If you would like to have taxes withheld, please check the box below: I would like federal and applicable state income taxes withheld from my IRA distribution being converted to a Roth IRA. I understand that, as a result, the portion of my IRA distribution that is withheld as income taxes will not be converted to my Roth IRA and may result in adverse tax consequences. If you would like more than 10% withheld, please indicate below: Federal taxes Percentage: Dollar amount % (minimum 10% distribution), or $ (Cannot be less than 10% of distribution.) State taxes* (Percentage or Dollars) Percentage: %, or Dollar amount $ *Percentage/dollar amount cannot be less than the minimum required for your state. MF1012 Ed. 6/2017 page 3 of 7

17 8. Authorization For Traditional IRAs, Roth IRAs, SEP-IRAs, and 403(b) accounts. It is my intention to effect a transfer, without inclusion of the amount to be transferred in my gross income. You are directed to transfer all or a portion of the redemption value of the account as identified in section 2 to an account established for me with Prudential Trust Company (PTC) as custodian. Accordingly, you are hereby directed to request on my behalf the transfer of my interest in the account referenced in section 2 for subsequent investment in Prudential Mutual Funds for investment in the custodial account(s) maintained for me. I hereby agree to the terms and conditions set forth in this Transfer/Direct Rollover/Conversion Authorization. For direct rollover. This authorizes the employer-sponsored retirement plan designated in section 2 to distribute my eligible rollover distribution directly from my retirement plan to PTC in accordance with the instructions in section 3. I have received and considered a copy of The Should You Rollover Your Retirement Plan? Challenge for applicable IRA rollovers. I understand that the conversion of a traditional IRA to a Roth IRA will result in a taxable event which will be reported to the IRS. If the account owner has attained the age of 70½ or older in the year of this transfer request, the required minimum distribution must be removed prior to the transfer being made. I understand that the resigning custodian may charge a closeout fee for IRA accounts. The default election is for the Resigning Custodian to redeem shares to cover charges. I authorize the resigning custodian to redeem shares to cover those charges. I will arrange to cover those charges by other means. Important: If elected, any fees must be paid to the resigning custodian prior to submitting this form, or they may deny the request. X Account owner s signature Date (mm/dd/yyyy) Important: If you are acting on behalf of the account owner, please indicate the capacity in which you are acting by checking the appropriate box below. If the correct box is not listed, please check Other and specify your capacity. Appointee under POA Other, please specify Place medallion signature guarantee here 9. Prudential Trust Company s Acceptance (To be completed by PMFS.) Prudential Mutual Fund Services LLC, as agent for the Prudential Trust Company (PTC) which is custodian of the traditional IRA, Roth IRA, SEP IRA or 403(b) plan, hereby confirms its acceptance of the above mentioned transfer or rollover. Authorized signature of Prudential Mutual Fund Services LLC (as agent for PTC) X MF1012 Ed. 6/2017 page 4 of 7

18 10. Financial Professional Identification and Signature (if applicable) Financial professional s name (first name, MI, last name) (Please print.) Financial professional s signature X Broker/Dealer s name (Please print.) Broker/Dealer number Branch/Agency number Rep./Contract number Branch telephone number Alternate telephone number MF1012 Ed. 6/2017 page 5 of 7

19 Prudential Mutual Fund Services LLC a Prudential Financial company Instructions & Disclosures For assistance: Clients: (800) Pruco Financial Professionals: (800) Financial Professionals: (888) About You Use this form to request a transfer of assets or transfer in kind from another custodian to Prudential Mutual Fund Services LLC (PMFS). Complete a separate transfer form for each sending institution. Include a copy of your most recent account statement with this form. Note: Prudential Mutual Fund Services LLC cannot accept stock certificates. Once we receive your transfer request and confirm that it is in good order, we will send a letter of acceptance to your current custodian requesting that the assets be sent to PMFS. Please follow up with your current custodian to determine the time frame for transferring your account to PMFS. Also, check with the resigning custodian about any financial penalties, suspensions, medallion signature guarantee, federal and state tax withholding elections or other restrictions that could affect the account proceeds that are being transferred to PMFS. If the account you are liquidating is subject to federal and state tax withholdings, then we suggest that you attach a letter of instruction to provide your withholding election for the resigning custodian. About the Account You are Transferring to PMFS Indicate the type of account and account number that you currently own which you would like the resigning custodian to liquidate or transfer to PMFS. Also, provide the name and address of the financial institution or employer-sponsored retirement plan from which the account will be liquidated or transferred. Transfer of Assets This section must only be completed if you own assets (other than Prudential Mutual Funds) and you want the proceeds to be liquidated and transferred to PMFS. Also, indicate any special instructions about when your account at the resigning custodian should be liquidated. Transfer-in-Kind This section should only be completed if you own existing Prudential mutual funds and want to change your current Trustee/Custodian to PMFS. If you own shares of Prudential mutual funds, those shares will not be liquidated. PMFS Account Type State the type of account you want the proceeds to be invested in at PMFS. MF1012 Ed. 6/2017 page 6 of 7

20 Mutual Fund Selection and Allocation If you are opening a new account, attach a completed IRA Application and we will follow the allocation instructions indicated on your IRA Application. You do not need to provide separate allocation instructions in this section of this form. If the transfer proceeds will be invested into an existing account, indicate in this section the fund(s) and the amount that should be allocated to each fund. Note: All allocations by percentage must total 100%. Refer to the fund s prospectus for the fund minimum and other important information about the fund(s) you have selected. Tax Withholding Election and Roth Conversion Disclosure Federal tax law requires income tax to be withheld at a rate of 10% from the total amount of your IRA distribution or conversion proceeds unless you elect not to have tax withheld. Depending on your state of residence, state tax withholding may also apply. Please consult with your tax advisor regarding the tax consequences of your distribution. Authorization Some resigning custodians require a medallion signature guarantee in order to transfer your account proceeds to PMFS. Please have your signature medallion guaranteed in this section if your current custodian requires a medallion signature. MF1012 Ed. 6/2017 page 7 of 7

21 Prudential Mutual Fund Services LLC (PMFS), a Prudential Financial company Authorization to Convert from a Traditional IRA to a Roth IRA For assistance: Clients: (800) Pruco representatives: (800) Financial professionals: (888) Instructions Use this form to request a distribution from your current PMFS traditional IRA and have the proceeds invested in a new or existing PMFS Roth IRA. Note: Conversion from a traditional IRA to a Roth IRA is a reportable, taxable event and may not be suitable for everyone. You should consult with your tax adviser to review the consequences of this conversion. Please follow these steps: Read the statement in section 6 and sign where indicated. Make sure you have received and read a copy of the Roth IRA Custodial Agreement and Disclosure Statement included with the IRA and Roth IRA Application. If you would like to add or to change the beneficiary designation on your Individual Retirement Account (IRA), please complete the MF 1001 Beneficiary Designation form. If you are a customer of a Prudential financial professional of Pruco Securities LLC, you must also complete the Pruco Investment Profile Questionnaire (MF1010) in addition to this form. If this form is not completed your request may be delayed. 1 Mutual Fund Account Ownership Information Name (first, MI, last name) Mr. Ms. Mrs. Mailing address City State ZIP code 4-digit ext Social Security number Date of birth Fund name (Specify portfolio and class of shares, if applicable.) Fund number Account number Daytime telephone number 2 Distribution Direction Prudential Mutual Fund Services LLC is hereby directed to complete this distribution from a traditional IRA and apply the proceeds to a Roth IRA dated: Date Note: The establishment date is the earliest date you either opened a Roth IRA or originally converted from a traditional IRA to a Roth IRA. This information is requested by the IRS for compliance with the 5-year IRS holding period requirement. Please be aware that if you are requesting a conversion into an existing Roth IRA, a separate 5-year holding period applies to each conversion. PMFS will only track the holding period for the initial transaction that established the Roth IRA. It is your responsibility to track the holding period for each subsequent conversion. MF1028 Ed. 4/2017 Page 1 of 2

22 3 4 Method of Distribution Please distribute the following amount from my traditional IRA (check one): Full distribution (100%) Partial distribution in the amount of $,. in cash Partial distribution for shares Fund Allocation I want the distribution indicated above to be invested into the following fund: Same fund as indicated in section 1 above New fund Existing account: Fund number Account number 5 Withholding Election and Roth Conversion Disclosure Federal tax law requires that income tax be withheld at a rate of 10% from the total amount of your IRA distribution/conversion unless you elect not to have tax withheld. Depending on your state of residence, state tax withholding may also apply. If you do not want taxes withheld, sign the election form below. By signing this form, you elect not to have taxes withheld. If you would like to have taxes withheld, please check the box below: I would like federal and applicable state income taxes withheld from my IRA distribution being converted to a Roth IRA. I understand that, as a result, the portion of my IRA distribution that is withheld as income taxes will not be converted to my Roth IRA and may result in adverse tax consequences. (Please consult with your tax adviser.) If you would like more than 10% withheld, please indicate below: Federal taxes Percentage: % (minimum 10% distribution), or Dollar amount $ State taxes* Percentage: %, or,. (Amount cannot be less than 10% of distribution.) Dollar amount $,. *Percentage/dollar amount cannot be less than the minimum required for your state. 6 Signature By signing below, I certify that: The information provided on this form regarding my status with respect to the account involved and all other aspects is correct. I understand that converting from a traditional IRA to a Roth IRA is a taxable event which will be reported to the IRS and I will be responsible for paying any income tax which might result from this conversion. I have received and read a copy of the Roth Individual Retirement Custodial Account Agreement, Disclosure Statement and applicable fund prospectuses. Sign here X Date Mailing Instructions for Mutual Fund Account Application Standard Prudential Mutual Fund Services LLC Overnight mail to: PO Box 9658 Providence, RI mail to: Prudential Mutual Fund Services LLC 4400 Computer Drive Westborough, MA MF1028 Ed. 4/2017 Page 2 of 2

23 Privacy Notice Prudential values your business and your trust. We respect the privacy of your personal information and take our responsibility to protect it seriously. This privacy notice is provided on behalf of the Prudential companies listed at the end of this notice (Prudential), and applies to our current and former customers. This notice describes how we treat the information we receive about you, including the ways in which we will share your personal information within Prudential and your right to opt out of such sharing. Protecting Your Personal Information We maintain physical, electronic and procedural safeguards to protect your personal information. The people who are authorized to have access to your personal information need it to do their jobs, and we require them to keep that information secure and confidential. Personal Information We Collect We collect your personal information when you fill out applications and other forms, when you enter personal details on our websites, when you respond to our s, and when you provide us information over the telephone. We also collect personal information that others give us about you. This information includes, for example: name address, address, telephone number, and other contact information income and financial information Social Security number transaction history medical information for insurance applications consumer reports from consumer reporting agencies participant information from organizations that purchase products or services from us for the benefit of their members or employees Using Your Information We use your personal information for various business purposes, including: normal everyday business purposes, such as providing services to you and administrating your account or policy business research and analysis marketing products and services of Prudential and other companies in which you may be interested as required by law Sharing Your Information We may share your personal information, including information about your transactions and experiences, among Prudential companies and with other non-prudential companies who perform services for us or on our behalf, for our everyday business purposes, such as providing services to you and administering your account or policy. We may also share your personal information with another financial institution if you agree that your account or policy can be transferred to that financial company. We may share your personal information among Prudential companies so that the Prudential companies can market their products and services to you. We may also share consumer report information among Prudential companies which may include information about you from credit reports and certain information that we receive from you and from consumer reporting agencies or other third parties. You can limit this sharing by following the instructions described in this notice. For those customers who have one of our products through a plan sponsored by an employer or other organization, we will share your personal information in a manner consistent with the terms of the plan agreement or consistent with our agreement with you. We may also share your personal information as permitted or required by law, including, for example, to law enforcement officials and regulators, in response to subpoenas, and to prevent fraud. Unless you agree otherwise, we do not share your personal information with non-prudential companies for them to market their products or services to you. We may tell you about a product or service that other companies offer and, if you respond, that company will know that we selected you to receive the information.

24 Limiting Our Sharing Opt Out/Privacy Choice You may tell us not to share your personal information among Prudential companies for marketing purposes, and not to share consumer report information among Prudential companies, by opting out of such sharing. To limit our sharing for these purposes: visit us online at: call us at: If you previously told us in 2016 or 2017 not to share your personal information among Prudential companies for marketing purposes, or not to share your consumer report information among Prudential companies, you do not need to tell us not to share your information again. You are not able to limit our ability to share your personal information among Prudential companies and with other non-prudential companies for servicing and administration purposes. Questions If you have any questions about how we protect, use, and share your personal information or about this privacy notice, please call us. The toll-free number is We reserve the right to modify this notice at any time. This notice is also available anytime at This notice is being provided to customers and former customers of the Prudential companies listed below. Insurance Companies and Insurance Company Separate Accounts The Prudential Insurance Company of America; Prudential Annuities Life Assurance Corporation; Pruco Life Insurance Company; Pruco Life Insurance Company of New Jersey; Prudential Retirement Insurance and Annuity Company (PRIAC); CG Variable Annuity Account I & II (Connecticut General); Pruco Legacy Insurance Company of New Jersey; All insurance company separate accounts that include the following names or are otherwise identified as maintained by an entity that includes the following names: Prudential, Pruco, or PRIAC Insurance Agencies Prudential Insurance Agency, LLC; Mullin TBG Insurance Agency Services, LLC Broker-Dealers and Registered Investment Advisers AST Investment Services, Inc.; Prudential Annuities Distributors, Inc.; Global Portfolio Strategies, Inc.; Pruco Securities, LLC; PGIM, Inc.; Prudential Investment Management Services LLC; PGIM Investments LLC; Prudential Private Placement Investors, L.P., Prudential Customer Solutions LLC; Quantitative Management Associates LLC Bank and Trust Companies Prudential Bank & Trust, FSB; Prudential Trust Company Investment Companies and Other Investment Vehicles Prudential Mutual Funds; Prudential Capital Partners, L.P.; The Target Portfolio Trust; Advanced Series Trust; Prudential Private Placement Investors, Inc.; All funds that include the following names: Prudential, PCP, PGIM, or PCEP Other Companies Prudential Retirement Strategic Investments, LLC Vermont Residents: We will not share information about your creditworthiness among Prudential companies, other than as permitted by Vermont law, unless you authorize us to make those disclosures. Prudential, the Prudential logo and the Rock symbol are service marks of Prudential Financial, Inc. and its related entities, registered in many jurisdictions worldwide. Privacy Ed. 1/2018

25 Roth Individual Retirement Custodial Account Agreement This Agreement governs the Participant s Prudential Roth Individual Retirement Custodial Account ( IRA ), and is made between the Depositor and the Custodian to establish a Roth Individual Retirement Custodial Account under section 408A of the Internal Revenue Code (the Code ) for the exclusive benefit of the Depositor and his or her beneficiaries. Actions by or for the Custodian shall also be deemed to include actions by or for the Custodian s designee (herein Prudential Mutual Fund Services, LLC, also referred to as PMFS). ARTICLE I DEFINITIONS 1. Application The application by which this Agreement, as it may be amended from time to time, is accepted by the Participant. The signed Application, and the statements contained therein, are an integral part of this Agreement. 2. Beneficiary The person or persons designated as such in the Application or as indicated in the latest subsequent written beneficiary designation received by the Custodian from the Participant. 3. Code The Internal Revenue Code of 1986, as amended from time to time. 4. Custodial Account The Individual Retirement Custodial Account established under this Agreement. The account is established for the exclusive benefit of the individual or his or her beneficiaries. The interest of an individual in the balance in his or her account is nonforfeitable at all times. 5. Depositor Individual who makes contributions to this or other Individual Retirement Accounts on his or her own behalf. 6. Disability The inability of an individual to engage in any substantial gainful activity by reason of any medically determined physical or mental impairment, which can be expected to result in death or to be of long, continued, and indefinite duration. An individual shall not be considered to be permanently and totally disabled unless he or she furnishes proof of the existence thereof in such form and manner, and at such times as the Internal Revenue Service (IRS) may require. 7. Fund Shares Mutual Fund Shares which are offered through Prudential Mutual Fund Services LLC (PMFS) for investment of Custodial Account assets. 8. Participant Each individual who has signed the Application accompanying this Agreement and on whose behalf contributions are made. This Agreement governs the Participant s Prudential Mutual Fund Individual Retirement Account ( IRA ), and is made between the Participant and the Custodian to establish an individual retirement custodial account under Section 408(a) of the Code for the exclusive benefit of the Participant and his or her beneficiaries. ARTICLE II 1. Maximum permissible amount Except in the case of a qualified rollover contribution or a recharacterization (as defined in II.4 below), no contribution will be accepted unless it is in the form of a check or other instrument acceptable by the Custodian. The total of such contributions to all the Depositor s Roth IRAs for a taxable year cannot exceed the applicable amount (See Applicable Amount, under II.2(c) below), or the Depositor s compensation (as defined in II.6 below), if less, for that taxable year. The contribution described in the previous sentence that does not exceed the lesser of the applicable amount or the Depositor s compensation is referred to as a regular contribution. It is the responsibility of the Depositor to determine whether any excess contribution has been made, the amount of the excess, the amount of any income earned on the excess contribution, and for the timely withdrawal or recharacterization of the appropriate amounts. A qualified rollover contribution is a rollover contribution of a distribution from an IRA that meets the requirement of Section 408(d)(3) of the Code, except the one-rollover-per-year rule of Section 408(d)(3)(B) does not apply if the rollover contribution is from an IRA other than a Roth IRA (a non-roth IRA ). ). For taxable years beginning after 2005, a qualified rollover contribution includes a rollover from a designated Roth account described in Code Section 402A; and for taxable years beginning after 2007, a qualified rollover contribution also includes a rollover from an eligible retirement plan described in 402(c)(8)(B). Contributions may be limited under II.2 through II.3 below. However, notwithstanding the dollar limits on contributions, an individual may make a repayment of a qualified reservist distribution described in Section 72(t)(2)(G) during the 2-year period beginning on the day after the end of the active duty period or by August 17, 2008, if later. 2. Regular contribution limit If (a) and/or (b) below apply, the maximum regular contribution that can be made to all the Depositor s Roth IRAs for a taxable year is the smaller amount determined under (a) or (b), as applied to the applicable amount under (c) below. After 2006, the dollar amounts above will be adjusted for cost-of-living increases under Section 408(A)(c)(3). Such adjustments will be in multiples of $1,000. (a) The maximum regular contribution is phased out ratably between certain levels of modified adjusted gross income ( modified AGI, defined in (I.5) below) in accordance with the following table: Filing Status Single or Head of Household Joint Return or Qualifying Widow(er) Married- Separation Return Full Contribution $95,000 or less $150,000 or less $0 Phase-out Range Modified AGI Between $95,000 & $110,000 Between $150,000 & $160,000 Between $0 & $10,000 No Contribution $110,000 or more $160,000 or more $10,000 or more If the Depositor s modified AGI for a taxable year is in the phase-out range, the maximum regular contribution determined under this table for that taxable year is rounded up to the next multiple of $10 and is not reduced below $200. (b) If the Depositor makes regular contributions to both Roth and non-roth IRAs for a taxable year, the maximum regular contribution that can be made to all the Depositor s Roth IRAs for that taxable year is reduced by the regular contributions made to the Depositor s non-roth IRAs for the taxable year. (c) Applicable Amount. The applicable amount is determined under (1) or (2) below: (1) If the Depositor will be under age 50 as of the end of the calendar year, the applicable amount is $3,000 for 2002 through 2004; $4,000 for years 2005 through 2007; and $5,000 for After 2008, the limit will be adjusted by the Secretary of the Treasury for costof-living increases under Code section 219(b)(5)(D). Such adjustments will be in multiples of $500. (2) If the Depositor will be 50 or older as of the end of the calendar year, the applicable amount is $3,500 for 2002 through 2004; $4,500 for 2005; $5,000 for 2006 and 2007; and $6,000 for After 2008, these limits will also be adjusted by the Secretary of the Treasury for cost-of-living increases under Code section 219(b)(5)(C). Such adjustments will be in multiples of $500. (3) If the individual was a participant in a Section 401(k) plan of a certain employer in bankruptcy described in Section 219(c)(5)(c), then the applicable amount under (1) above is increased by $3,000 for taxable years beginning after 2006 and before 2010 only. An individual who makes contributions under this paragraph may not also make contributions under paragraph (2). 1