Notification of Divorce and Division Instructions Variable Annuities are issued by Pruco Life Insurance Company, in New York, by Pruco Life Insurance Company of New Jersey and The Prudential Insurance Company of America (PICA) (these entities are referred to as Prudential below). All are Prudential Financial, Inc. companies and each is solely responsible for its own financial condition and obligations. The Rock Prudential Logo is a registered service mark of PICA and its affiliates. The purpose of this form is to facilitate the transfer, distribution, or change of ownership of a Prudential deferred annuity and to facilitate the distribution of an immediate annuity as a result of divorce proceedings. If you have a Qualified Life contract please call our call center at (888) 778-2888. This form is required by Prudential in lieu of a Divorce Decree/Property Settlement Agreement/Qualified Domestic Relations Order and such documentation should not be submitted with this form. When this form and all additional requirements have been deemed by Prudential to be in good order, the contract specified below will be divided pursuant to the instructions contained herein. Instructions: You may be required to attach additional documentation as stated in this form. All information must be typed or printed using blue or black ink. This form is not for use with divorce proceedings in Ohio. A separate Notification of Divorce & Division Instructions form must be submitted for each Prudential contract to be divided. On these pages, I, you and your refer to the contract owner(s). We, us and our refer to the Prudential company that issued the contract. For 403(b) contracts a Request for Withdrawal from 403(b)/Tax-Sheltered Annuity ( TSA ) form is also required. For Federal tax purposes, the term spouse includes any individuals who are lawfully married in a jurisdiction (including a State, District of Columbia, US territory or foreign country) that recognizes same sex marriage. Federal law does not recognize domestic partnerships or civil unions that are not designated as married under state law. Therefore, we are required to report any distribution or change of ownership pursuant to a divorce between civil unions or domestic partners as a taxable distribution. You may wish to consult with your tax advisor. SECTION 1 OWNER INFORMATION Annuity Number Telephone Number Owner Name (First, Middle, Last Name) Owner Social Security/Tax I.D. Number Street Date of Birth City State ZIP Code If we require additional information to complete this request, please indicate who Prudential should contact: Owner Financial Professional Other party in interest: Relationship to owner must be checked (check one): Former Spouse Domestic Partner Civil Union Partner Name (First, Middle, Last Name) Telephone Number Social Security/Tax I.D. Number Street Date of Birth City State ZIP Code ORD 207226 Ed. 11/15 p1 of 12
SECTION 2 ANNUITY TYPE AND ARRANGEMENT Please Indicate The Type of Annuity Contract To Be Divided. Non-Qualified. By signing section 7 of this form you represent and assert that you: a) have entered into a separation agreement or obtained a divorce decree that meets the requirements of Internal Revenue Code ( IRC ) Section 1041(a); and b) have consulted with an attorney and/or tax advisor concerning this divorce related transaction.* Roth IRA, IRA/SEP. By signing section 7 of this form, you represent and assert that you: a) have entered into a separation agreement or obtained a divorce decree that meets the requirements of Internal Revenue Code ( IRC ) Section 408(d)(6); and b) have consulted with an attorney and/or tax advisor concerning this divorce-related transaction.* 403(b) Tax Deferred Annuities. By signing section 7 of this form, you represent and assert that you have entered into a Qualified Domestic Relations Order ( QDRO ) that meets the requirements of Internal Revenue Code ( IRC ) Section 402(e)(1)(A). Non-Transferable Annuity. By signing section 7 of this form, you represent and assert that you have entered into a Qualified Domestic Relations Order ( QDRO ) that meets the requirements of Internal Revenue Code ( IRC ) Section 402(e)(1)(A). Not available for Premier Retirement or Premier Advisor. 457/Qualified Plans. By signing section 7 of this form, you represent and assert that you have entered into a Qualified Domestic Relations Order ( QDRO ) that meets the requirements of Internal Revenue Code ( IRC ) Section 402(e)(1)(A). Your Plan Administrator/Trustee must also sign this form. Other (Please explain.) * If you are currently taking substantially equal payments under Internal Revenue Code ( IRC ) Section 72(q) or 72(t), you may wish to consult with your tax advisor to determine what effect, if any, this distribution will have on your payment stream. SECTION 3 NON-DISTRIBUTION OPTIONS (PLEASE CHOOSE ONE OPTION THEN PROCEED TO SIGNATURE SECTION) Ownership change to former spouse (Non-qualified) - Please note that when we change the ownership to the former spouse the beneficiary will be changed to his/her estate. If you would like the beneficiary to be someone else, please complete Section 5, Beneficiary Change. Change of ownership could impact your optional benefits. Please see your prospectus for details. Please complete the new owner information below. Transfer/Direct Rollover (IRA,SEP, Roth, 403(b)) - Process a Transfer/Direct Rollover within the same contract. Please note that when we process this change to the former spouse, the beneficiary will be changed to his/her estate. If you would like the beneficiary to be someone else, please complete Section 5, Beneficiary Change. This change could impact your optional benefits. Please see your prospectus for details and complete the owner information below. Taxable Ownership Change for Domestic Partner/Civil Union - Process this request as a taxable ownership change. This option is available to same-sex civil union partners, domestic partners or same-sex spouses not recognized by federal tax law. By electing this option you become the new owner of the contract. If the contract in question is a tax qualified contract, the contract will be reclassified as a non-qualified annuity going forward. Any taxable gain at the time of the change will be reported to the former owner and the IRS on a Form 1099-R. If you would like the beneficiary to be someone else, please complete Section 5, Beneficiary Change. This change could impact your optional benefits. Please see your prospectus for details and complete the owner information below. Remove the Divorce Hold If the ownership of your annuity contract will be changing as a result of your divorce and you have a non-spousal optional living benefit, your benefit will terminate and the guarantees under the benefit will not be transferred to the new owner. However, if you have a spousal optional living benefit, the benefit will remain on the annuity contract as a result of the ownership change. Please call our Annuities Service Center with any questions. Name of New Owner (First, Middle, Last Name) New Owner Social Security/Tax I.D. Number Street Date of Birth City State ZIP Code Telephone Number ORD 207226 Ed. 11/15 p2 of 12
SECTION 4A DISTRIBUTION OPTIONS (SPOUSE) Note: Depending on the option selected additional paperwork may be required. Please choose A, B, C or D Any Systematic Withdrawal program scheduled for less than or equal to the Annual Income Amount (AIA), or equal to the Annual Withdrawal Amount (AWA, for Lifetime Five (LT5)) will be cancelled if a partial withdrawal request is processed. You must submit a new Systematic Withdrawal form if you wish to establish a new program. Any Systematic Withdrawal program scheduled for greater than your AIA, or AWA (for LT5) will not be cancelled if a partial withdrawal request is processed. For an immediate annuity, payments can only be split or directed to alternate payee. A. Transfer the amount indicated below to a new contract with Prudential pursuant to the attached application. Please include an Annuity Application in the name of the recipient/former spouse. You can locate a Financial Professional in your area by calling 1-888-778-2888. B. Send the amount indicated below to an existing Prudential contract. Contract Number C. Transfer the amount indicated above to a new contract at another insurance carrier. For non-qualified or to another Roth IRA, IRA, SEP or 403(b) contract or employer plan pursuant to the attached paperwork. Please include the following: If the proceeds are payable from a nonqualified annuity: 1035 Exchange paperwork from the new insurance company. If the proceeds are payable from a Roth IRA, IRA, SEP, 403(b) contract or employer plan, Trustee-to-Trustee Transfer/ Rollover paperwork from the other carrier must be provided. For 403(b) contracts a Request for Withdrawal from 403(b)/Tax-Sheltered Annuity ( TSA ) form is also required. D. Send the amount indicated below as a lump sum*. *Please complete section 6 in the Income Tax Withholding Notice And Election if this option is chosen. Payable to former spouse Current Owner Owner Retention of Spousal Optional Living Benefit - please choose one option. NOTE: If no selection is made the transaction will not be processed (Only available to contract owners with Spousal Lifetime Five (Spousal LT5), Spousal Highest Daily Lifetime Seven (Spousal HD7), Spousal Highest Daily Lifetime Seven with BIO (Spousal HD7 BIO), Spousal Highest Daily Lifetime 7 Plus (Spousal HD7 Plus), Spousal Highest Daily Lifetime 7 Plus with BIO (Spousal HD7 Plus BIO), Spousal Highest Daily Lifetime 6 Plus (Spousal HD6 Plus), Spousal Highest Daily Lifetime Income (Spousal HDI), Spousal Highest Daily Lifetime Income 2.0 (Spousal HDI v2.0), Spousal Highest Daily Lifetime Income 2.0 with Highest Daily Death Benefit (Spousal HDI v2.0 HD DB), Spousal Highest Daily Lifetime Income 2.0 with Highest Annual Death Benefit (Spousal HDI v2.0 HA DB), Spousal Highest Daily Lifetime Income v2.1 (Spousal HDI v2.1), Spousal Highest Daily Lifetime Income v2.1 with Highest Daily Death Benefit (Spousal HDI v2.1 HD DB), Spousal Highest Daily Lifetime Income v2.1 with Highest Annual Death Benefit (Spousal HDI v2.1 HA DB), Spousal Highest Daily Lifetime Income v3.0 (Spousal HDI v3.0), Spousal Highest Daily Lifetime Income v3.0 with Highest Daily Death Benefit (Spousal HDI v3.0 HD DB), or Spousal Highest Daily Lifetime Income v3.0 with Highest Annual Death Benefit. (Spousal HDI v3.0 HA DB)). Continue Benefit - If you continue your Spousal Optional Living Benefit your fee charges will not be reduced. The Designated Lives will remain the same from the time the benefit was elected. The benefit will terminate upon the death of the Designated Life that retains ownership. Refer to the prospectus for additional information regarding benefit termination. Terminate Benefit - If you terminate your Spousal Optional Living Benefit you will lose all guarantees under the benefit. The Current Annuity and Benefit Values section must be completed and the most recent values must be provided in order for the request to be processed. This form must be received in our office in good order within 10 business days of the As Of date indicated on Section below. 1. Input Current Account Value My Account Value is: $ as of Date: Market Value Adjustment (if applicable): $ (Continued) ORD 207226 Ed. 11/15 p3 of 12
SECTION 4A DISTRIBUTION OPTIONS (SPOUSE) continued 2. Input Applicable Benefit Information & Guarantee Values For Spousal versions of LT5, HD5, HD7, HD7 Plus, HD6 Plus, HDI, HDI 2.0, HDI v2.1 and HDI v3.0 My Protected Withdrawal Value (PWV) is: My AIA is: $ $ My AWA is: (for Lifetime Five only) $ If the Designated Lives divorce, the Spousal Optional Living Benefit may not be divided as part of the divorce settlement or judgement. Designated Lives are natural persons who are each other s spouses at the time of election of the benefit and at the death if the first of the Designated Lives to die. In addition, the divorcing spouse who retains ownership of the annuity cannot appoint a new Designated Life upon remarriage. Non-Lifetime Withdrawal Only available to contract owners with Highest Daily Lifetime 7 Plus suite (HD7 Plus), Highest Daily Lifetime 6 Plus suite (HD6 Plus), Highest Daily Lifetime Income suite (HDI), Highest Daily Lifetime Income 2.0 suite (HDI 2.0), Highest Daily Lifetime Income v2.1 suite (HDI v2.1) or Highest Daily Lifetime Income v3.0 (HDI v3.0) Suite of Benefits. This withdrawal will not result in the calculation of the initial AIA. You may only request one Non-Lifetime Withdrawal under your benefit and once processed, it may not be reversed. This withdrawal will proportionately reduce all guarantees provided under your benefit based on the percent this withdrawal amount (including any applicable CDSC) represents of your Account Value at the time of the withdrawal. Please refer to the prospectus for further details. You must choose one of the following options. (Prudential will not calculate the amount to be transferred based on units) The portion of the contract to be withdrawn/transferred to the former spouse as identified above is as follows: Dollar amount $ OR Percent % NOTE: Dollar Amount or Percent cannot be calculated based on units. Elections greater than your AIA, or AWA (for LT5) will result in excess withdrawals. Important: Date the Percentage will be calculated: (Month / Day / Year) Are gains and losses attributable to the former spouse s withdrawal? Yes No If Yes, the effective date of the gains and losses will be calculated as of the date all requirements have been deemed completed by Prudential unless otherwise indicated here. (Month / Day / Year) Please be aware that there may be contractual charges that would apply to a distribution taken from this annuity. In addition, we are unable to split Surrender Charges among the spouses. Therefore, please choose one of the options below. If neither option is chosen we will default to gross. Please choose one option. NOTE: If no selection is made the withdrawal will be taken on a GROSS basis. Net amount (Check will be for the amount indicated above. Any applicable contingent deferred sales charges and/or federal and state taxes will be deducted from the contract value, this may cause a withdrawal in excess of the AIA or AWA (for LT5).) Gross amount (Check will be for the amount indicated above, less any applicable contingent deferred sales charges and/or federal and state taxes.) ORD 207226 Ed. 11/15 p4 of 12
SECTION 4B DISTRIBUTION OPTIONS (DOMESTIC PARNTERSHIP/CIVIL UNION) (Any distribution made to a former domestic partner/civil union partner will be taxable to the current contract owner) For an immediate annuity, payments can only be split or directed to an alternate payee. Send the amount indicated below to: A new contract with Prudential pursuant to the attached application. Please include an Annuity Application in the name of the recipient/ former domestic partner/civil union partner. You can locate a Financial Professional in your area by calling 1-888-778-2888. An exisiting Prudential Contract Number Lump sum payable to former domestic partner/civil union partner Lump sum payable to current owner If one of the above options is chosen, please complete section 6 in the Income Tax Withholding Notice and Election. Non-Lifetime Withdrawal Only available to contract owners with Highest Daily Lifetime 7 Plus suite (HD7 Plus), Highest Daily Lifetime 6 Plus suite (HD6 Plus), Highest Daily Lifetime Income suite (HDI), Highest Daily Lifetime Income 2.0 suite (HDI 2.0), Highest Daily Lifetime Income v2.1 suite (HDI v2.1) or Highest Daily Lifetime Income v3.0 (HDI v3.0) Suite of Benefits. This withdrawal will not result in the calculation of the initial AIA. You may only request one Non-Lifetime Withdrawal under your benefit and once processed, it may not be reversed. This withdrawal will proportionately reduce all guarantees provided under your benefit based on the percent this withdrawal amount (including any applicable CDSC) represents of your Account Value at the time of the withdrawal. Please refer to the prospectus for further details You must choose one of the following options. (Prudential will not calculate the amount to be transferred based on units) The portion of the contract to be withdrawn/transferred to the former domestic partner/civil union partner as identified above is as follows: Dollar amount $ OR Percent % NOTE: Dollar Amount or Percent cannot be calculated based on units. Elections greater than your AIA, or AWA (for LT5) will result in excess withdrawals. Important: Date the Percentage will be calculated: (Month / Day / Year) Are gains and losses attributable to the former domestic partner/civil union partner withdrawal? Yes No If Yes, the effective date of the gains and losses will be calculated as of the date all requirements have been deemed completed by Prudential unless otherwise indicated here. (Month / Day / Year) Please be aware that there may be contractual charges that would apply to a distribution taken from this annuity. In addition, we are unable to split Surrender Charges among the former domestic partner/civil union partner. Therefore, please choose one of the options below. If neither option is chosen we will default to gross. Please choose one option. NOTE: If no selection is made the withdrawal will be taken on a GROSS basis. Net amount (Check will be for the amount indicated above. Any applicable contingent deferred sales charges and/or federal and state taxes will be deducted from the contract value, this may cause a withdrawal in excess of the AIA or AWA (for LT5).) Gross amount (Check will be for the amount indicated above, less any applicable contingent deferred sales charges and/or federal and state taxes.) ORD 207226 Ed. 11/15 p5 of 12
SECTION 5 BENEFICIARY CHANGE (All fields below must be completed.) To select a Predetermined payout method for your beneficiary please complete the Beneficiary and Predetermined Payout Election Form. I hereby request the following Beneficiary. All beneficiary(ies) previously designated will be revoked unless requested otherwise in writing by the owner(s). Please check primary or contingent for each individual beneficiary. If neither is checked, the individual will be deemed to be a primary beneficiary. All beneficiaries in a class are assumed to share equally unless requested otherwise in writing by the Owner(s). For Massachusetts residents - state law requires that a disinterested adult who is not a party to the contract witness any request to change the beneficiary arrangement. Note: Your Investment Professional can sign as a witness. If a Trust is named as a beneficiary, the name of the Trust, the inception date of the Trust, and the trustee name(s) are require in order for us to process the request. (All fields below must be completed.) Beneficiary Name (First, Middle, Last Name) Primary Contingent Male Female Percentage % Telephone Number Relationship to Owner / Trustee name(s) if Trust Date of Birth Social Security/Tax I.D. Number Street City State ZIP Code Beneficiary Name (First, Middle, Last Name) Primary Contingent Male Female Percentage % Telephone Number Relationship to Owner / Trustee name(s) if Trust Date of Birth Social Security/Tax I.D. Number Street City State ZIP Code Beneficiary Name (First, Middle, Last Name) Primary Contingent Male Female Percentage % Telephone Number Relationship to Owner / Trustee name(s) if Trust Date of Birth Social Security/Tax I.D. Number Street City State ZIP Code (Continued) ORD 207226 Ed. 11/15 p6 of 12
IMPORTANT NOTICES: Any Systematic Withdrawal program scheduled for less than or equal to the AIA or equal to the AWA (for LT5) will be cancelled if a partial withdrawal request is processed. You must submit a new Systematic Withdrawal form if you wish to establish a new program. Any Systematic Withdrawal program scheduled for greater than your AIA or AWA (for LT5) will not be cancelled if a partial withdrawal request is processed. For the LT5, HD5 and HD7 benefit suites: The Protected Withdrawal Value (PWV) is determined as of the date you make your first withdrawal under the Annuity following your election of the benefit. For the HD7 Plus, HD6 Plus, HDI, HDI 2.0, HDI v2.1 or HDI v3.0 Suite of Benefits: The PWV is determined at the time of first Lifetime Withdrawal under the Annuity following your election of the benefit. A systematic withdrawal cannot be taken as a Non- Lifetime withdrawal and all systematic withdrawals will be treated as Lifetime Withdrawals under these benefits. Withdrawals are subject to all of the terms and conditions of the Annuity, including any applicable CDSC and MVA. Withdrawals made while the benefit is in effect will be treated, for tax purposes, in the same way as any other withdrawals under the Annuity. If you have a benefit and are taking withdrawals pro-rata, these withdrawals will be taken from all sub-accounts (including the AST Investment Grade Bond Sub-account or Benefit Fixed Rate Account as applicable) and the DCA Options, including any 6 or 12 month DCA Program you may be participating in. Withdrawals from an MVA Option more than 30 days prior to the end of the Guarantee Period will be subject to a Market Value Adjustment, which can either increase or decrease your Account Value. Premature withdrawals from any 6 or 12 Month DCA MVA Program you may be participating in may also be subject to a Market Value Adjustment. Please refer to your current prospectus for further details. Excess Withdrawals An excess withdrawal refers to a withdrawal that (i) exceeds your AIA or your AWA (for LT5) and (ii) is not a required minimum distribution calculated by Prudential and distributed under a program that we administer. If you take an excess withdrawal, it proportionally reduces your AIA or AWA (for LT5) and will result in a permanent reduction to your AIA or AWA (for LT5) available in current and future annuity years. Excess withdrawals will proportionally reduce the future PWV amount. If you would like to make an excess withdrawal and are uncertain how an excess withdrawal will reduce your future AIA or AWA (for LT5), then you may contact us prior to requesting the withdrawal to obtain a personalized, transaction-specific calculation showing the effect of the excess withdrawal. For Contracts Enrolled In A Systematic Withdrawal Program: Any partial withdrawals taken while a Systematic Withdrawal program is in effect may cause you to exceed your AIA or AWA (for LT5). Also, certain partial withdrawals may cause your Systematic Withdrawal program to be canceled. In addition, each systematic withdrawal you take that is an excess withdrawal will proportionally reduce your AIA or AWA (for LT5) and will further reduce the value of your benefit including a permanent reduction to your AIA or AWA (for LT5) available in current and future annuity years. Please monitor your AIA or AWA (for LT5) carefully and review your Systematic Withdrawal program prior to taking partial withdrawals. Gross amount vs. net amount election:when a withdrawal that is subject to a CDSC and/or tax withholding, we use not only the amount you actually receive, but also the amount of the CDSC and/or tax withholding, to determine whether your withdrawal is an excess withdrawal. You may request a gross withdrawal amount and have any CDSC and/or tax withholding deducted from the amount you actually receive or a net withdrawal amount and have any CDSC and/or tax withholding deducted from your remaining Unadjusted Account Value. The portion of a withdrawal that exceeds your AIA or AWA (for LT5) would be considered an excess withdrawal. Although an MVA may also be applied to your remaining Unadjusted Account Value, it is not considered for purposes of determining an excess withdrawal. Charge Free Amount: If you participate in a benefit and you make a withdrawal, you should be aware of whether the withdrawal is subject to a CDSC and how the withdrawal could affect the AIA or AWA (for LT5) under this benefit. If your withdrawal does not exceed the AIA or AWA (for LT5), it will not be subject to a CDSC - even if the withdrawal exceeds the free withdrawal amount. On the other hand, a withdrawal can come within the free withdrawal amount (for purposes of not incurring a CDSC) but be in excess of the AIA or AWA (for LT5). In that scenario, the withdrawal would be deemed Excess Income - thereby resulting in a permanent reduction to the AIA or AWA (for LT5) available to you in current and future years. ORD 207226 Ed. 11/15 p7 of 12
SECTION 6 INCOME TAX WITHHOLDING NOTICE AND ELECTION If this section is left blank, you are electing to NOT have Federal or State taxes withheld. However, you will still be liable for any applicable taxes. In certain circumstances including, but not limited to, what is described in section 7, Prudential may be required to withhold taxes. For all Michigan residents, please make an election in the box below. I elect: Not to have Federal or State income taxes withheld. 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%), or $ To have State income taxes withheld on the taxable portion of my distribution, as indicated below: % or $ NOTE: The percent or dollar amount cannot be less than the minimum required by your state of residence. If the amount you selected is less, we will withhold the required default amount. 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. For 401(a) and 403(b) 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), or another plan qualified under Internal Revenue Code section 401(a). The taxable portion of the withdrawal that you receive will be subject to Federal income tax withholding and State income tax withholding, where applicable, unless you elect not to have withholding apply. The taxable portion of your withdrawal will normally be subject to Federal income tax withholding at a rate of 10% for non-annuity payments, and is based on withholding tables for annuity payments. Your withdrawal may also be subject to State income tax withholding in certain states. If this contract is a 401(a) Qualified plan or a 403(b) Tax Deferred Annuity, we are required to withhold a minimum 20% for Federal taxes. In addition, Michigan residents must complete the following. Please choose one: Michigan law now requires 4.25% income tax withholding from pension and retirement benefits, unless your payments are not taxable, or you opt out. Please check the appropriate box below if you are a Michigan resident. Your pension or annuity payments are not taxable or you wish to opt out. Note: Opting out may result in a balance due on your MI-1040 as well as penalties and interest. % Total percentage you want withheld from your annuity payment(s) (must be at least 4.25%). If no selection is made, we will withhold 4.25% ORD 207226 Ed. 11/15 p8 of 12
SECTION 7 SIGNATURES For a Partial Exchange of Assets received or disbursed on or after 10/24/2011: Internal Revenue Procedure 2011-38 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 2011-38 provides that a partial direct transfer as described above will be treated as a tax-free 1035 exchange if no distributions 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. This form must be completed and signed by the contract owner and the former spouse, domestic partner or civil union partner. Both signatures must be notarized. By signing below, I acknowledge: Excess withdrawals will permanently reduce the AIA or AWA (for LT5) available to me in current and future Annuity Years. Any Systematic Withdrawal program scheduled for less than or equal to the AIA or equal to the AWA (for LT5) will be cancelled if a partial withdrawal request is processed. Any Systematic Withdrawal program scheduled for greater than your AIA or AWA (for LT5) will not be cancelled if a partial withdrawal request is processed. Furthermore, I: Agree to the ownership change made on this form. Understand that if this contract contains certain optional benefits, Prudential may not be able to accommodate this request. I will be notified by Prudential should this be the case. Certify that no other person has any claim or interest in the contract except for an assignee under any assignment now on record with Prudential. Certify that I am aware that this transaction will be reported to the IRS as a taxable distribution to the former domestic partner/civil union partner who receives the distribution. Proceeds received from a Roth IRAs, IRAs, SEPs, 403(b)s, 457s or employer plans may be eligible for rollover within 60 days. You may wish to contact your tax advisor for more information. You are attesting that the instructions provided to Prudential on this form are in accordance with your separation agreement, divorce decree, or QDRO (if applicable). You acknowledge that it is your responsibility to consult with an attorney and/or tax advisor on the effect your choice has, under applicable tax and other law, with respect to this divorce-related transaction, and that Prudential is not providing you with legal or tax advice. Furthermore, you agree to waive, release, discharge, and forever hold harmless Prudential and its affiliates, and officers, directors, and employees from and against any liability incurred by the contract owner, former spouse or former domestic partner/civil union partner that may arise from or in connection with accepting and acting on the instructions being provided to Prudential on this form. There may be tax implications as a result of this request(s), including requests to pay advisory fees, 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. Note that 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. (Continued) ORD 207226 Ed. 11/15 p9 of 12
SECTION 7 SIGNATURES (continued) If not a U.S. person (including resident alien), submit the applicable Form W-8 (BEN, ECI, EXP or IMY). OWNER S TAX CERTIFICATION (SUBSTITUTE 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 an SSN/TIN may result in mandatory tax withholding. I further certify that: I am a U.S. citizen or other U.S. person (including resident alien). I am not a U.S. citizen or other U.S. person (including resident alien). I am a citizen of. I have been notified by the Internal Revenue Service that I am subject to backup withholding due to underreporting of interest and dividends. (Prudential is required to withhold income tax on any payments which include interest and dividends when the owner is subject to backup withholding.) I am subject to the reporting requirements of the Foreign Account Tax Compliance Act (FATCA). If not a U.S. person (including resident alien), submit the applicable Form W-8 (BEN, ECI, EXP or IMY). FORMER SPOUSE OR DOMESTIC PARTNER/CIVIL UNION PARTNER TAX CERTIFICATION (SUBSTITUTE W-9) Former Spouse or Domestic Partner/Civil Union Partner 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 an SSN/TIN may result in mandatory tax withholding. I further certify that: I am a U.S. citizen or other U.S. person (including resident alien). I am not a U.S. citizen or other U.S. person (including resident alien). I am a citizen of. I have been notified by the Internal Revenue Service that I am subject to backup withholding due to underreporting of interest and dividends. (Prudential is required to withhold income tax on any payments which include interest and dividends when the owner is subject to backup withholding.) I am subject to the reporting requirements of the Foreign Account Tax Compliance Act (FATCA). The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding. IMPORTANT Signatures must be notarized. If signed on the same date one notary is required. If signed on separate dates a separate notary is required for each signature. SIGN HERE Owner s signature Date of signature (Month / Day / Year) SIGN HERE Notary Signature (Seal 1) SIGN HERE Former Spouse s or Domestic Partner/Civil Union Partner signature Date of signature (Month / Day / Year) SIGN HERE Notary Signature (Seal 2) REQUIRED (Seal 1) (Seal 2) IMPORTANT Signatures must be notarized. If signed on the same date one notary is required. If signed on separate dates a separate notary is required for each signature. Employer Signature and Title Date of signature (Month / Day / Year) All withdrawals from a 403(b) contract must be signed by the employer. ORD 207226 Ed. 11/15 p10 of 12
AN ADMINISTRATOR/TRUSTEE SIGNATURE The Plan Administrator/Trustee certifies that a domestic relations order that constitutes a Qualified Domestic Relations Order (QDRO), as defined in the Internal Revenue Code (IRC) Section 414(p), including the provisions relating to the Alternate Payee s access to allocated amounts, has been issued in the dissolution of the marriage of and, and the above instructions reflect the order of the court and terms of the plan/contract. In addition, the Plan Administrator/Trustee acknowledges that the division requested represents the agreement of the parties, and is subject to any restrictions under the Plan/Contract. The Plan administrator/trustee authorizes the Company to establish an account for benefit of the Alternate Payee and/or make payment(s) as permitted by the Plan/Contract to the Alternate Payee from the Participant s/owners account pursuant to the information provided on the QDRO Certification Form. SIGN HERE Plan Administrator s Signature (if applicable) Date of signature (Month / Day / Year) IMPORTANT TAX INFORMATION We present this information based on our understanding of tax law. You may wish to consult with a tax or legal advisor because neither we nor our representatives can provide tax or legal advice. Federal and state income tax withholding. Federal and some state tax laws require us to withhold income taxes from certain cash payments unless you elect out of withholding and in certain other circumstances. We are required to withhold federal income taxes and certain state income taxes from the taxable portion of any withdrawal from a non-qualified annuity, an IRA, a Roth IRA, a Section 403(b) tax-deferred annuity, or a Section 401(a) qualified plan. If your withdrawal is from a Section 403(b) tax-deferred annuity or a Section 401(a) qualified plan, and is an eligible rollover distribution, you will not be able to elect out of federal income tax withholding. Federal taxes will be withheld at a 20% rate, unless you elect to have your eligible rollover distribution directly rolled over to an IRA or to another qualified plan. You will not be able to elect out of withholding if we are notified that your taxpayer identification number (TIN) is incorrect. Estimated tax and possible penalties. 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. You may be subject to IRS penalties including fines and imprisonment, if you fail to provide your correct taxpayer identification number (TIN), fail to report taxable interest or dividends on your tax return, or give false tax information. You may be subject to a 10% federal income tax penalty if you are under the age of 59½. Taxpayer identification number and U.S. citizenship. You must certify your TIN in section 7. If the contract owner is an individual, this is the Social Security number. You must state whether you are or are not a U.S. citizen. If you are not a U.S. person or resident alien, you must provide the country of which you are a citizen and submit the applicable IRS Form W-8(BEN, ECI, EXP, IMY). In most situations, the IRS Form W-8BEN will be the appropriate IRS Form W-8. Backup withholding. You must tell us if the IRS has notified you that you are subject to backup withholding because you did not report all your taxable interest and dividends on your tax return. You are not subject to backup with-holding if you did not receive such a notice from the IRS, or if the IRS recently told you that you are no longer subject to a backup withholding order. If you have been notified that you are subject to backup withholding, please check the appropriate box in section 7. If the contract is held by a trustee as agent for an individual or by a grantor trust, the individual for whom the contract is held or the grantor must complete a substitute Form W-9 and attach it to this form in order not to be subject to backup withholding. Annuities Service Center Investor Line: 1-888-778-2888 Financial Professionals: 1-800-513-0805 8:00AM 7:00PM ET, Monday Thursday 8:00AM 6:00PM ET, Friday Fax: (800) 576-1217 www.prudentialannuities.com Regular Mail Delivery Annuities Service Center P.O. Box 7960 Philadelphia, PA 19176 Overnight Service, Certified or Registered Mail Delivery Prudential Annuities Service Center 2101 Welsh Road Dresher, PA 19025 ORD 207226 Ed. 11/15 p11 of 12
IMPORTANT REQUIRED INFORMATION FOR ALL NEW OWNERS USA Patriot Act Identify Information To help the government fight the funding of terrorist and money laundering activities, Federal Law requires all financial institutions to obtain, verify, and record information that identifies each person/entity that owns an account. What this means: When a person/entity becomes the owner of an account, we will ask for the new owner s name, address, date of birth, social security number, acting trustee/officer name(s) and other information that will allow us to identify the new owner. We may also request other identifying documents necessary for verification purposes. We may verify the information provided with a national database or similar verification system. This verification process will take place as we process the change to the new person/entity. Once verification is completed, we will be able to fully service and maintain the account. Annuities Service Center Investor Line: 1-888-778-2888 Financial Professionals: 1-800-513-0805 8:00AM 7:00PM ET, Monday Thursday 8:00AM 6:00PM ET, Friday Fax: (800) 576-1217 www.prudentialannuities.com Regular Mail Delivery Annuities Service Center P.O. Box 7960 Philadelphia, PA 19176 Overnight Service, Certified or Registered Mail Delivery Prudential Annuities Service Center 2101 Welsh Road Dresher, PA 19025 ORD 207226 Ed. 11/15 p12 of 12