Withdrawal Request Questions? Call our Variable Annuity Service Center at

Transcription

1 Withdrawal Request Questions? Call our Variable Annuity Service Center at We will only accept responsibility for forms mailed to the address at right. Overnight Mailing Address Mail Zone SW 6th Street Topeka, KS Allstate Life Insurance Company P.O. Box Topeka, KS FAX Instructions Use this form to request a one-time withdrawal from your account. Complete each section of the form. Charges may apply to withdrawals. Please note if you are 70-1/2 or older and currently have a Required Minimum Distribution (RMD) program established on your account any additional withdrawals taken from your account will be considered part of the RMD for the current year. The number of remaining payments and/or the amount of your systematic RMD may change due to this withdrawal request. If your account is a retirement savings or governmental 457 plan, please refer to the applicable Special Tax Notice attached for a summary of the options available to you. Due to strict IRS regulations governing investment accounts we recommend that you evaluate your situation carefully and/or consult with your tax advisor to maintain the status of your account and/or to avoid any potential penalties. Tax Sheltered Account withdrawals may not be made from elective deferral contributions received or earnings credited after December 31, 1988, unless the withdrawal is due to any of the reasons indicated in Section 2. If you have a SureIncome SM Withdrawal Benefit Option (SureIncome, SureIncome Plus, or SureIncome For Life) attached to your contract, please note that a distribution request may exceed or may cause any systematic distributions to exceed the allowed withdrawal amount under your SureIncome Withdrawal Benefit Option. Please type or print. 1. Provide General Account Information Contract Number Name of Owner/Participant Name of Joint Owner First MI Last First MI Last Mailing Address Street Address City State ZIP Code Social Security Number/Tax I.D. Number Daytime Phone Number Marital Status: 0 Single 0 Married Home Phone Number Date of Birth (mm/dd/yyyy) 2. Reason for Distribution Only complete this section if you have a qualified account. Please select all that apply. 0 Age 59-1/2 0 Disabled (shall have the meaning set forth in section 72(m)(7) of the Internal Revenue Code (IRC)) 0 Severance from Employment on (includes retirement, termination, change of employment) (mm/dd/yyyy) We are required to wait 30 days prior to Processing any request for a Direct Rollover or a distribution paid directly to you so that you can consider your request. Unless you check the box below, by signing this request you have waived the 30-day notice period. 0 I do not wish to waive the 30 day notice period. Note: by checking this box your funds will be held for 30 days. Employer signature is required if the contract does not have a Grandfathered status. 0 RMD (required after age 70-1/2) PRU (04/17) 1/7

2 0 Hardship I certify that my employer has determined this distribution is necessary to satisfy an immediate and heavy financial need, as described in the Internal Revenue Code and the accompanying regulations, which cannot be satisfied from insurance, reasonable liquidation of my assets, cessation of elective deferrals to my 403(b), or other distributions or loans from my employer s plans or a commercial loan. I understand that this distribution cannot exceed the amount necessary to satisfy the financial need and may only be made from salary deferral amounts and not the earn- ings attributable to them. IRS regulations require that further contributions be prohibited for a period of six months from the date of the withdrawal. 0 Unforeseeable Emergency Please provide a detailed description: (Only applicable to 457 Plans) 0 Qualified Domestic Relations Order - A copy must be attached along with a fully completed Instruction of Divorce and Transfer Instructions Form.) After review of the QDRO, additional documentation may be required depending on the circumstances and the division instructions. 0 Removal of Excess Contributions - Current Year 0 Removal of Excess Contributions - Prior Year (prior year must be removed by April 15th of current year.) 3. Select the Withdrawal Type Please indicate the type of withdrawal. If no option is selected, a gross withdrawal will be processed. 0 Gross The requested withdrawal will be reduced by any applicable surrender charges, fees and tax withholding. 0 Net The requested withdrawal amount will be increased by any applicable surrender charges, fees and tax withholding, so that the resulting check is equal to your requested amount. 4. Select the Amount Please indicate how much you would like to withdraw from your account: 0 Full 0 Policy Enclosed 0 Policy Lost or Destroyed 0 Partial $ 0 Free Withdrawal 0 Calculate my RMD based on the Uniform Lifetime Method using the value in this account. If the spouse is more than 10 years younger than the owner/participant, the RMD may be reduced. If you wish to reduce your RMD, please provide your Spouse s Date of Birth (mm/dd/yyyy) PRU (04/17) 2/7

3 5. Distribution Instructions Please indicate how the funds are to be withdrawn. If an option is not selected the funds will be withdrawn prorata. 0 Prorata proportionately as the funds are currently invested. 0 Specific funds as indicated below: PERCENTAGES MUST TOTAL 100% DOLLARS MUST EQUAL TOTAL AMOUNT REQUESTED 6. How do you want to receive your distribution? Please select how you want to receive this amount. From Investment Option 0 Electronic Funds Transfer (EFT) to my bank account proceeds will arrive within 3 business days after the withdrawal. 0 Wire Transfer to my bank account a $20.00 wire processing fee will be assessed. 0 Send check to address of record as indicated on this form. PRU (04/17) 3/7

4 7. Provide Bank Information Only complete this section if you selected EFT or Wire Transfer above. Please provide your bank information below. If any information is missing your request may be delayed. Bank Account Type (please check one): 0 Checking 0 Savings Bank Name Name on Bank Account Bank Routing Number Bank Account Number (Do not include check number) DO NOT INCLUDE CHECK NUMBER Routing Number Account Number Date $ 0001 Dollars Income Tax Withholding Notice and Election If this section is left blank then you are electing to not have Federal or State taxes withheld. However, you will still be liable for any applicable taxes. There may be tax implications as a result of this request(s) and the request(s) (including tax reporting and withholding) cannot be reversed once processed. Please consult tax and/or legal counsel before proceeding. Please refer to your annuity contract and prospectus for provisions and tax considerations regarding withdrawals prior to submitting this form. I elect: To have 10% Federal income taxes withheld on the taxable portion of my distribution. To have more than 10% Federal income taxes withheld on the taxable portion of my distribution, as indicated below: % (minimum 10 percent), or $,,. To have State income taxes withheld on the taxable portion of my distribution, as indicated below:,,. NOTE: Your withdrawal may also be subject to State Income tax withholding in certain states. The percent or dollar amount cannot be less than the minimum required by your State of residence. If the amount you select is less, we will withhold the required default amount. If your resident State requires mandatory withholding, we will withhold the default amount your State requires even if you elect no withholding. If you elect to have no income tax withheld from your withdrawal, or if you do not have enough income tax withheld from your withdrawal, you may be responsible for payment of estimated tax. You may incur penalties if your withholding and estimated tax payments are not sufficient. This election will remain in effect until you revoke it. You may change your withholding election on future payments by notifying us. For 401(a) The eligible rollover portion of your distribution is subject to a mandatory 20 percent federal income tax withholding unless directly rolled to a traditional IRA, a 457 (governmental plan), or another plan qualified under Internal Revenue Code section 401(a). If you are a U.S. person (including resident alien), and your address of record is a non-u.s. address, we are required to withhold income tax unless you provide us with a U.S. residential address. If applicable, please include your U.S. residential address with this form. PRU (04/17) 4/7

5 9. Loan Acknowledgement If your account has an active loan and you are requesting a full withdrawal you must acknowledge the following statement by checking the box below. 0 I understand in order to process this full withdrawal request all loans on the account must be paid in full by me or through a loan surrender. A loan surrender will result in a taxable event. If the loan is surrendered, a 1099 will be issued after year end, for the amount subject to taxation. This acknowledgement is required or my request will be denied. Restrictions on IRA/Roth IRA Funds received from the distribution of an IRA (if converted to a Roth IRA), or from a Roth IRA must be deposited into another Roth IRA within 60 days after they are received. This period may be extended to 120 days for certain rollovers relating to qualified first-time home buyer distributions. When counting days, weekends and holidays are included. "Day 1" is the day after the distribution is received. There are generally no exceptions to the 60-day rule and the IRS generally will not grant extensions. Please be advised that effective for distributions on or after January 1, 2015, the limit of one 60- day IRA to IRA rollover per 12 month period, outlined in section 408(d)(3)(B), applies on an aggregate basis to all IRAs owned by an individual, regardless of institution. This is based on the Tax Court ruling in Bobrow v. Commissioner, detailed in Announcement by the IRS. This 12 month limit does not apply to IRA to IRA transfers. Please consult your tax advisor. You are entitled to take one distribution from your Roth IRA every 12 months for purposes of being rolled over to another Roth IRA. Rollovers made during or after the year in which the owner turns age 70, cannot be made from assets representing a Required Minimum Distribution from an IRA, 403(b) or 401(a). 10. Important Information Regarding Partial 1035 Exchanges For a Partial Exchange of Assets received or disbursed on or after October 24, 2011: Internal Revenue Procedure applies to the direct transfer of a portion of the cash surrender value of an existing annuity contract for another annuity contract, regardless of whether the annuity contracts are issued by the same or different companies. Revenue Procedure provides that a partial direct transfer as described above will be treated as a tax-free 1035 exchange if no distribu-tions are made from either of the two contracts for 180 days following the date of the transfer. If a distribution from either contract occurs during the 180 day period following the date of the transfer, the IRS will apply general tax principles to determine the substance and treatment of the transfer. (continued) PRU (04/17) 5/7

6 11. Tax Certification and Signatures Required Signatures: IRA and Non-Qualified accounts Owner(s) Only 403(b) TSA accounts Both Owner(s) and Employer 401(a) and 401(k) Plans Both Participant and Plan Sponsor 457 Plans Both Participant and Plan Sponsor (if applicable) NOTE: If applicable, a signature is required for all irrevocable beneficiaries. IMPORTANT: I understand that if I have an active 72(t) or 72(q) program on this account, that the program will be terminated prior to processing this request, and that the termination may result in the retroactive application of the 10% early withdrawal penalty. I understand that the company will not be liable for any unfavorable tax consequences resulting from the termination of this program. I accept all responsibility for any taxes and penalties due as a result of this action. Note: If you are a U.S. person (including resident alien), and your address of record is a non-u.s. address, we are required to withhold income tax unless you provide us with a U.S. residential address. I understand, acknowledge and certify that: I am solely responsible for all tax obligations, or possible tax penalties, arising from this withdrawal, and for compliance with the laws, regulations and restrictions governing such withdrawals. Failure to follow the rules on a tax-qualified account can jeopardize the tax protected status of the account and result in the imposition of penalties, additional taxes and interest for which I will be solely responsible. If this is a Hardship Withdrawal, I further certify (a) that the payment requested does not exceed the total amount needed by me to meet this hardship and pay the applicable taxes; and (b) that my financial need cannot be satisfied through any of the following: reimbursement or compensation by insurance; reasonable liquidation of my assets; cessation of contributions; other distributions or nontaxable loans from plans maintained by an employer; or borrowing from commercial sources on reasonable commercial terms. The information provided within this form is accurate and true, including my tax identification number. You must cross out item 2 if you have been notified that you are subject to backup withholding. Cross out item 3 if you are not a U.S person (including U.S resident alien) or U.S. Entity and attach a completed Form W-8 (BEN, ECI, EXP, IMY). Owner's Tax Certification (Substitute Form W-9) Owner Social Security /Tax I.D. Number Under penalties of perjury, I certify that the taxpayer identification number (SSN/TIN) I have listed on this form is my correct SSN/TIN. Failure to provide a SSN/TIN may result in mandatory tax withholding. I further certify that: 0 I am a U.S. citizen or other U.S. person (including resident alien) 0 I am not a U.S. citizen or other U.S. person (including resident alien). I am a citizen of. 0 I have been notified by the Internal Revenue Service that I am subject to back up withholding due to underreporting of interest and dividends. (We are required to withhold income tax on any payments which include interest and dividends when the owner is subject to backup withholding.) 0 I am subject to the reporting requirements of the Foreign Account Tax Compliance Act (FATCA). Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and 2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and 3. I am a U.S.person (including U.S. resident alien). x The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding. Signature of Owner/Participant Date (mm/dd/yyyy) Signature of Joint Owner (if applicable) Date (mm/dd/yyyy) x Signature of Plan Sponsor Date (mm/dd/yyyy) Title x Signature of Representative (optional) Date (mm/dd/yyyy) Print Name of Representative x PRU (04/17) 6/7

7 By signing below, the employer confirms that the conditions for this withdrawal, as indicated in this form, have been met. x Signature of Employer Date (mm/dd/yyyy) Employer Title Spousal Consent for Community Property States: If the owner/participant is a resident of AZ, CA, ID, LA, NM, NV, TX, WA or WI, spousal consent is required, unless the owner/participant has no legal spouse. x Signature of Spouse Signature Guarantee Stamp Date (mm/dd/yyyy) Signature Guarantee: If required, place stamp in the box to the right. Additional 72(t)/(q) disclosure: I understand that the substantially equal periodic payment amounts may not be varied, and that once such payments commence, the only permitted changes that I may make are to: * Change or correct my address * Adjust my income tax withholding, or * Change the date on which the distributions are made, provided that the number of payments for the year and the total annual payment amount does not change. If a partial surrender of a full surrender is processed after a 72(t)/(q) stream of payments has been established, then the 72(t)/(q) schedule is terminated and the prior payments will be treated as regular distributions. Payments will only be reported as excepted from the 10% federal income tax penalty if no changes other than the ones described above are made. PRU (04/17) 7/7

8 Important Notices: The rules related to 72(t)/(q) program are very complex. Please read all of the information on this form and consult with your tax advisor before proceeding. Section 72(t)/(q) of the IRC imposes a 10% penalty tax on distributions made before age 59 1/2 from qualified retirement plans. IRC 72(t)/(q) relates to IRAs and pensions. An exception to the 10% penalty is allowed if distributions are made as "part of a series of substantially equal periodic payments". To meet the definition of "substantially equal periodic payments" under Section 72(t)/(q), the distributions must: 1. Continue unaltered for the longer of 5 years or until the owner reaches age 59 1/2, and 2. Be based on the life or life expectancy of the owner, or joint lives or joint expectancies of owner and designated beneficiary, and 3. Be made at least annually (i.e., annually, semiannually, quarterly, monthly). 4) 72(t)/(q) frequencies cannot be changed once the program has started. While your 72(t)/(q) program is in effect no additional contributions can be made to your annuity contract after your 72(t)/(q) withdrawals begin or after the date you have chosen to value your annuity, if earlier. SPECIAL TAX NOTICE REGARDING PLAN PAYMENTS QUALIFIED UNDER 401(A), 403(A) ANNUITY PLANS, 403(B) TAX SHELTERED ANNUITIES, OR 457(B) GOVERNMENTAL PLANS This notice is provided to you by Allstate Life Insurance Company because all or a portion of your payment that you will soon receive from your employer s plan may be eligible for rollover by you to an IRA or an eligible employer plan. This notice is intended to help you decide whether to do such a rollover. This notice describes the rollover rules that apply to payments from your employer s plan that are not from a designated Roth account (a type of account with special tax rules in some employer plans). If you also receive a payment from a designated Roth account in the Plan, you will be provided a different notice for that payment, and the Plan administrator or the payor will tell you the amount that is being paid from each account. Rules that apply to most payments from a plan are described in the General Information About Rollovers section. Special rules that only apply in certain circumstances are described in the Special Rules and Options section. The Internal Revenue Code provides several complex rules relating to the taxation of the amounts you receive in this distribution. This notice merely summarizes these rules, and the information contained herein has been taken from a model notice prepared by the Internal Revenue Service. Please note that the Company and its agents and representatives assume no responsibility for the accuracy of this model notice, and cannot provide you with the tax or legal advice with respect to these issues. You should promptly consult a tax advisor in deciding what course of action to follow with respect to this distribution. If you have additional questions after reading this notice, you can contact your plan administrator. GENERAL INFORMATION ABOUT ROLLOVERS How can a rollover affect my taxes? You will be taxed on a payment from the Plan if you do not roll it over. If you are under age 59 1/2 and do not do a rollover, you will also have to pay a 10% additional income tax on early distributions (unless an exception applies). However, if you do a rollover, you will not have to pay tax until you receive payments later and the 10% additional income tax will not apply if those payments are made after you are age 59 1/2 (or if an exception applies). PRU (04/17) 1/8 Leave with Customer

9 Restrictions on IRA/Roth IRA Funds received from the distribution of an IRA (if converted to a Roth IRA), or from a Roth IRA must be deposited into another Roth IRA within 60 days after they are received. This period may be extended to 120 days for certain rollovers relating to qualified first-time home buyer distributions. When counting days, weekends and holidays are included. "Day 1" is the day after the distribution is received. There are generally no exceptions to the 60-day rule and the IRS generally will not grant extensions. Please be advised that effective for distributions on or after January 1, 2015, the limit of one 60-day IRA to IRA rollover per 12 month period, outlined in section 408(d)(3)(B), applies on an aggregate basis to all IRAs owned by an individual, regardless of institution. This is based on the Tax Court ruling in Bobrow v. Commissioner, detailed in Announcement by the IRS. This 12 month limit does not apply to IRA to IRA transfers. Please consult your tax advisor. You are entitled to take one distribution from your Roth IRA every 12 months for purposes of being rolled over to another Roth IRA. Rollovers made during or after the year in which the owner turns age 70, cannot be made from assets representing a Required Minimum Distribution from an IRA, 403(b) or 401(a). Where may I roll over the payment? You may roll over the payment to either an IRA (an Individual Retirement Account or Individual Retirement Annuity) or an employer plan (a tax-qualified plan, section 403(b) plan, or governmental section 457(b) plan) that will accept the rollover. The rules of the IRA or employer plan that holds the rollover will determine your investment options, fees, and rights to payment from the IRA or employer plan (for example, no spousal consent rules apply to IRAs and IRAs may not provide loans). Further, the amount rolled over will become subject to the tax rules that apply to the IRA or employer plan. How do I do a rollover? There are two ways to do a rollover. You can do either a direct rollover or a 60-day rollover. If you do a direct rollover, your payment will be made directly to your IRA or an employer plan. You should contact the IRA sponsor or the administrator of the employer plan for information on how to do a direct rollover. If you do not do a direct rollover, you may still do a rollover by making a deposit into an IRA or eligible employer plan that will accept it. You will have 60 days after you receive the payment to make the deposit. If you do not do a direct rollover, the Plan is required to withhold 20% of the payment for federal income taxes (up to the amount of cash and property received other than employer stock). This means that, in order to roll over the entire payment in a 60-day rollover, you must use other funds to make up for the 20% withheld. If you do not roll over the entire amount of the payment, the portion not rolled over will be taxed and will be subject to the 10% additional income tax on early distributions if you are under age 59 1 /2 (unless an exception applies). Your Right to Waive the 30-Day Notice Period: A distribution will not be made to you until 30 days after you receive this Special Tax Notice. During the 30 days following your receipt of this Special Tax Notice, you may decide whether or not you want to elect a direct rollover. If you do not wish to wait until this 30-day notice period ends before your election is processed, you may waive the notice period by making an affirmative election indicating whether or not you wish to make a direct rollover. Your withdrawal will then be processed in accordance with your election as soon as practical after it is received by the Payor. How much may I roll over? If you wish to do a rollover, you may roll over all or part of the amount eligible for rollover. Any payment from the Plan is eligible for rollover, except: Certain payments spread over a period of at least 10 years or over your life or life expectancy (or the lives or joint life expectancy of you and your beneficiary); PRU (04/17) 2/8 Leave with Customer

10 Required minimum distributions after age 70 1/2 (or after death); Hardship distributions; ESOP dividends; Corrective distributions of contributions that exceed tax law limitations; Loans treated as deemed distributions (for example, loans in default due to missed payments before your employment ends); Contributions made under special automatic enrollment rules that are withdrawn pursuant to your request within 90 days of enrollment; Amounts treated as distributed because of a prohibited allocation of S corporation stock under an ESOP (also, there will generally be adverse tax consequences if you roll over a distribution of S corporation stock to an IRA). The Plan administrator can tell you what portion of the payment is eligible for rollover. If I don t do a rollover, will I have to pay the 10% additional income tax on early distributions? If you are under age 59 1 /2, you will have to pay the 10% additional income tax on early distributions for any payment from the Plan (including amounts withheld for income tax) that you do not roll over, unless one of the exceptions listed below applies. This tax is in addition to the regular income tax on the payment not rolled over. The 10% additional income tax does not apply to the following payments from the Plan: Payments made after you separate from service if you will be at least age 55 in the year of separation; Payments that start after you separate from service if paid at least annually in equal or close to equal amounts over your life or life expectancy (or the lives or joint life expectancy of you and your beneficiary); Payments from a governmental defined benefit pension plan made after you separate from service if you are a public safety employee and you are at least age 50 in the year of the separation; Payments made due to disability; Payments after your death; Payments of ESOP dividends; Corrective distributions of contributions that exceed tax law limitations; Contributions made under special automatic enrollment rules that are withdrawn pursuant to your request within 90 days of enrollment; Payments made directly to the government to satisfy a federal tax levy; Payments made under a qualified domestic relations order (QDRO); Payments up to the amount of your deductible medical expenses; Certain payments made while you are on active duty if you were a member of a reserve component called to duty after September 11, 2001 for more than 179 days; Payments of certain automatic enrollment contributions requested to be withdrawn within 90 days of the first contribution. PRU (04/17) 3/8 Leave with Customer

11 If I do a rollover to an IRA, will the 10% additional income tax apply to early distributions from the IRA? If you receive a payment from an IRA when you are under age 59 1/2, you will have to pay the 10% additional income tax on early distributions from the IRA, unless an exception applies. In general, the exceptions to the 10% additional income tax for early distributions from an IRA are the same as the exceptions listed above for early distributions from a plan. However, there are a few differences for payments from an IRA, including: There is no exception for payments after separation from service that are made after age 55. The exception for qualified domestic relations orders (QDROs) does not apply (although a special rule applies under which, as part of a divorce or separation agreement, a tax-free transfer may be made directly to an IRA of a spouse or former spouse). The exception for payments made at least annually in equal or close to equal amounts over a specified period applies without regard to whether you have had a separation from service. There are additional exceptions for (1) payments for qualified higher education expenses, (2) payments up to $10,000 used in a qualified first-time home purchase, and (3) payments after you have received unemployment compensation for 12 consecutive weeks (or would have been eligible to receive unemployment compensation but for self-employed status). Will I owe State income taxes? This notice does not describe any State or local income tax rules (including withholding rules). This form, and the information contained within, is not intended as investment advice and is not a recommendation about managing or investing your retirement savings. In providing these materials, the entity(ies) set forth on this form are not acting as your fiduciary as defined by any applicable laws and regulations. Please consult with your qualified investment professional about managing or investing your retirement savings. PRU (04/17) 4/8 Leave with Customer

12 SPECIAL RULES AND OPTIONS If your payment includes after-tax contributions After-tax contributions included in a payment are not taxed. If a payment is only part of your benefit, an allocable portion of your after-tax contributions is generally included in the payment. If you have pre-1987 after-tax contributions maintained in a separate account, a special rule may apply to determine whether the after-tax contributions are included in a payment. You may roll over to an IRA a payment that includes after-tax contributions through either a direct rollover or a 60-day rollover. You must keep track of the aggregate amount of the after-tax contributions in all of your IRAs (in order to determine your taxable income for later payments from the IRAs). If you do a direct rollover of only a portion of the amount paid from the Plan and a portion is paid to you, each of the payments will include an allocable portion of the aftertax contributions. If you do a 60-day rollover to an IRA of only a portion of the payment made to you, the after-tax contributions are treated as rolled over last. For example, assume you are receiving a complete distribution of your benefit which totals $12,000 of which $2,000 is after-tax contributions. In this case, if you roll over $10,000 to an IRA in a 60-day rollover, no amount is taxable because the $2,000 amount not rolled over is treated as being after-tax contributions. You may roll over to an employer plan all of a payment that includes after-tax contributions, but only through a direct rollover (and only if the receiving plan separately accounts for after-tax contributions and is not a governmental section 457(b) plan). You can do a 60-day rollover to an employer plan of part of a payment that includes after-tax contributions, but only up to the amount of the payment that would be taxable if not rolled over. If you miss the 60-day rollover deadline Generally, the 60-day rollover deadline cannot be extended. However, the IRS has the limited authority to waive the deadline under certain extraordinary circumstances, such as when external events prevented you from completing the rollover by the 60-day rollover deadline. To apply for a waiver, you must file a private letter ruling request with the IRS. Private letter ruling requests require the payment of a nonrefundable user fee. For more information, see IRS Publication 590, Individual Retirement Arrangements (IRAs). If your payment includes employer stock that you do not roll over If you do not do a rollover, you can apply a special rule to payments of employer stock (or other employer securities) that are either attributable to after-tax contributions or paid in a lump sum after separation from service (or after age 59 1/2, disability, or the participant s death). Under the special rule, the net unrealized appreciation of the stock will not be taxed when distributed from the Plan and will be taxed at capital gain rates when you sell the stock. Net unrealized appreciation is generally the increase in the value of employer stock after it was acquired by the Plan. If you do a rollover for a payment that includes employer stock (for example, by selling the stock and rolling over the proceeds within 60 days of the payment), the special rule relating to the distributed employer stock will not apply to any subsequent payments from the IRA or employer plan. The Plan administrator can tell you the amount of any net unrealized appreciation. If you have an outstanding loan that is being offset If you have an outstanding loan from the Plan, your Plan benefit may be offset by the amount of the loan, typically when your employment ends. The loan offset amount is treated as a distribution to you at the time of the offset and will be taxed (including the 10% additional income tax on early distributions, unless an exception applied) unless you do a 60-day rollover in the amount of the loan offset to an IRA or employer plan. If you were born on or before January 1, 1936 If you were born on or before January 1, 1936 and receive a lump sum distribution that you do not roll over, special rules for calculating the amount of the tax on the payment might apply to you. For more information, see IRS Publication 575, Pension and Annuity Income. PRU (04/17) 5/8 Leave with Customer

13 If your payment is from a governmental section 457(b) plan If the Plan is a governmental section 457(b) plan, the same rules described elsewhere in this notice generally apply, allowing you to roll over the payment to an IRA or an employer plan that accepts rollovers. One difference is that, if you do not do a rollover, you will not have to pay the 10% additional income tax on early distributions from the Plan even if you are under age 59 1 /2 (unless the payment is from a separate account holding rollover contributions that were made to the Plan from a tax-qualified plan, a section 403(b) plan, or an IRA). However, if you do a rollover to an IRA or to an employer plan that is not a governmental section 457(b) plan, a later distribution made before age 59 1 /2 will be subject to the 10% additional income tax on early distributions (unless an exception applies). Other differences are that you cannot do a rollover if the payment is due to an unforeseeable emergency and the special rules under If your payment includes employer stock that you do not roll over and If you were born on or before January 1, 1936 do not apply. If you are an eligible retired public safety officer and your pension payment is used to pay for health coverage or qualified long-term care insurance If the plan is a governmental plan, you retired as a public safety officer, and your retirement was by reason of disability or was after normal retirement age, you can exclude from your taxable income plan payments paid directly as premiums to an accident or health plan (or a qualified long-term care insurance contract) that your employer maintains for you, your spouse, or your dependents, up to a maximum of $3,000 annually. For this purpose, a public safety officer is a law enforcement officer, firefighter, chaplain, or a member of a rescue squad or ambulance crew. If you roll over your payment to a Roth IRA You can roll over a payment from the Plan made before January 1, 2010 to a Roth IRA only if your modified adjusted gross income is not more than $100,000 for the year the payment is made to you and if married, you file a joint return. These limitations do not apply to payments made to you from the Plan after If you wish to roll over the payment to a Roth IRA, but you are not eligible to do a rollover to a Roth IRA until after 2009, you can do a rollover to a traditional IRA and then, after 2009, elect to convert the traditional IRA into a Roth IRA. If you roll over the payment to a Roth IRA, a special rule applies under which the amount of the payment rolled over (reduced by any after-tax amounts) will be taxed. However, the 10% additional income tax on early distributions will not apply (unless you take the amount rolled over out of the Roth IRA within 5 years, counting from January 1 of the year of the rollover). For payments from the Plan during 2010 that are rolled over to a Roth IRA, the taxable amount can be spread over a 2-year period starting in If you roll over the payment to a Roth IRA, later payments from the Roth IRA that are qualified distributions will not be taxed (including earnings after the rollover). A qualified distribution from a Roth IRA is a payment made after you are age 59 1/2 (or after your death or disability, or as a qualified first-time homebuyer distribution of up to $10,000) and after you have had a Roth IRA for at least 5 years. In applying this 5-year rule, you count from January 1 of the year for which your first contribution was made to a Roth IRA. Payments from the Roth IRA that are not qualified distributions will be taxed to the extent of earnings after the rollover, including the 10% additional income tax on early distributions (unless an exception applies). You do not have to take required minimum distributions from a Roth IRA during your lifetime. For more information, see IRS Publication 590, Individual Retirement Arrangements (IRAs). You cannot roll over a payment from the Plan to a designated Roth account in an employer plan. If you are not a plan participant (surviving spouses, alternate payees, and other beneficiaries) Payments after death of the participant. If you receive a distribution after the participant s death that you do not roll over, the distribution will generally be taxed in the same manner described elsewhere in this notice. However, the 10% additional income tax on early distributions and the special rules for public safety officers do not apply, and the special rule described under the section If you were born on or before January 1, 1936 applies only if the participant was born on or before January 1, PRU (04/17) 6/8 Leave with Customer

14 If you are a surviving spouse If you receive a payment from the Plan as the surviving spouse of a deceased participant, you have the same rollover options that the participant would have had, as described elsewhere in this notice. In addition, if you choose to do a rollover to an IRA, you may treat the IRA as your own or as an inherited IRA. An IRA you treat as your own is treated like any other IRA of yours, so that payments made to you before you are age 59 1 /2 will be subject to the 10% additional income tax on early distributions (unless an exception applies) and required minimum distributions from your IRA do not have to start until after you are age 70 1 /2. If you treat the IRA as an inherited IRA, payments from the IRA will not be subject to the 10% additional income tax on early distributions. However, if the participant had started taking required minimum distributions, you will have to receive required minimum distributions from the inherited IRA. If the participant had not started taking required minimum distributions from the Plan, you will not have to start receiving required minimum distributions from the inherited IRA until the year the participant would have been age 70 1 /2. If you are a surviving beneficiary other than a spouse If you receive a payment from the Plan because of the participant s death and you are a designated beneficiary other than a surviving spouse, the only rollover option you have is to do a direct rollover to an inherited IRA. Payments from the inherited IRA will not be subject to the 10% additional income tax on early distributions. You will have to receive required minimum distributions from the inherited IRA. Payments under a qualified domestic relations order If you are the spouse or former spouse of the participant who receives a payment from the Plan under a qualified domestic relations order (QDRO), you generally have the same options the participant would have (for example, you may roll over the payment to your own IRA or an eligible employer plan that will accept it). Payments under the QDRO will not be subject to the 10% additional income tax on early distributions. If you are a nonresident alien If you are a nonresident alien and you do not do a direct rollover to a U.S. IRA or U.S. employer plan, instead of withholding 20%, the Plan is generally required to withhold 30% of the payment for federal income taxes. If the amount withheld exceeds the amount of tax you owe (as may happen if you do a 60-day rollover), you may request an income tax refund by filing Form 1040NR and attaching your Form 1042-S. See Form W-8BEN for claiming that you are entitled to a reduced rate of withholding under an income tax treaty. For more information, see also IRS Publication 519, U.S. Tax guide for Aliens, and IRS Publication 515, Withholding of Tax on Nonresident Aliens and Foreign Entities. Other special rules If a payment is one in a series of payments for less than 10 years, your choice whether to make a direct rollover will apply to all later payments in the series (unless you make a different choice for later payments). If your payments for the year are less than $200 (not including payments from a designated Roth account in the Plan), the Plan is not required to allow you to do a direct rollover and is not required to withhold for federal income taxes. However, you may do a 60-day rollover. Unless you elect otherwise, a mandatory cashout of more than $1,000 (not including payments from a designated Roth account in the Plan) will be directly rolled over to an IRA chosen by the Plan administrator. A mandatory cashout is a payment from a plan to a participant made before age 62 (or normal retirement age, if later) and without consent, where the participant s benefit does not exceed $5,000 (not including any amounts held under the plan as a result of a prior rollover made to the plan). You may have special rollover rights if you recently served in the U.S. Armed Forces. For more information, see IRS Publication 3, Armed Forces Tax guide. PRU (04/17) 7/8 Leave with Customer

15 FOR MORE INFORMATION You may wish to consult with the Plan administrator or a professional tax advisor before taking a payment from the Plan. Also, you can find more detailed information on the federal tax treatment of payments from employer plans in: IRS Publication 575, Pension and Annuity Income; IRS Publication 571, Tax-Sheltered Annuity Plans (403(b) Plans. These publications are available from a local IRS office, on the web at or by calling TAX-FORM. This form, and the information contained within, is not intended as investment advice and is not a recommendation about managing or investing your retirement savings. In providing these materials, the entity(ies) set forth on this form are not acting as your fiduciary as defined by any applicable laws and regulations. Please consult with your qualified investment professional about managing or investing your retirement savings. PRU (04/17) 8/8 Leave with Customer