Annuity Full Surrender Request 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. Use this form to surrender your annuity contract. For 403(b) withdrawals, the 403(b) Tax Sheltered Annuity Form MUST be used. Instructions: All information must be typed or printed using blue or black ink. SECTION 1 OWNER AND WITHDRAWAL INFORMATION Annuity Number E-mail Address Owner Name (First, Middle, Last Name) Joint Owner Name (If applicable) Telephone Number Mobile Number Annuitant Name (First, Middle, Last Name) If this request is received within 10 calendar days of your contract anniversary, and your contract is still subject to surrender charges, Prudential can hold your request until the anniversary date to reduce the amount of contingent deferred sales charges. By checking this box, you authorize Prudential to process this request as of the contract anniversary and not the date it is received. Please send me periodic service alerts via text message. By checking the box above, you are agreeing to receive periodic service alerts from Prudential, each of which may be delivered to your mobile 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 www.prudential.com/prualertstandc. If we require additional information to complete this request, please indicate who Prudential should contact: Owner Financial Professional SECTION 2 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 5, 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 $ (Continued) ORD 78276A Ed. 11/15 p1 of 5
SECTION 2 INCOME TAX WITHHOLDING NOTICE AND ELECTION (continued) 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) 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). 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% SECTION 3 CERTIFICATION OF DISABILITY This information is used to determine if a disability exception to the 10% federal income tax penalty on premature distributions is applicable. Distribution due to total and permanent disability. By checking this box I certify that I meet the Internal Revenue Service s definition of Disabled, which requires that an individual be unable to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or to be of long-continued and indefinite duration. If this box is not checked a premature/normal distribution based on age will be reported. ORD 78276A Ed. 11/15 p2 of 5
SECTION 4 PAYMENT AND MAILING INSTRUCTIONS A. Payment Instructions Direct Deposit (ACH) to a Bank Please allow 1-3 business days from the processing date to receive the funds in your bank account. See check illustration below for help in completing this section and attach a voided check where indicated. Bank Name Bank telephone number Bank account number ABA routing number (To ensure accuracy, verify with your bank.) Type of Account Checking Savings Name of depositor on bank records ATTACH A VOIDED CHECK WHERE INDICATED (REQUIRED FOR NEW EFT/ACH REQUESTS and CHANGES TO EXISTING EFT/ACH INSTRUCTIONS). If a voided check is not attached a check will be sent to the owner s address of record. If requesting funds sent to a Savings Account we require account information from the bank. Please note that deposit slips for savings accounts may not provide accurate EFT/ ACH routing information - we suggest checking with the bank prior to submitting your request. Requests for third party EFT are not permitted. Funds must be sent to the Owner s bank account. (first, middle initial, last name) Providing a voided check or bank letter that does not show the name of the owner and/or a current address can cause delays in sending your funds as requested. OR make check payable to: Owner (Address of Record or specify address below.) Special payee (Requires a Signature Guarantee in section 5. Please enter special payee s name and address below.) If this money is being forwarded to another carrier, a letter of acceptance from the receiving carrier must be submitted in addition to this form if the transfer is to be reported as a non-taxable event. Please allow 3-5 days from the processing date to receive your funds by U.S. First Class Mail. Checks cannot be mailed directly to your Financial Professional s branch office. If your Financial Professional s branch office is provided, the check will be made payable to the contract owner and mailed to the Address of Record. Name of special payee if selected above Street City State ZIP Code Country OR Direct Payment to a Brokerage Account: Existing account Brokerage Account Number Brokerage account must be on file with Prudential. If the Brokerage account is not on file, a check will be made payable to the contract owner and mailed to the Address of Record. B. Check Mailing Instructions If an overnight delivery is desired, it is at your own expense. This cost cannot be deducted from the Annuity. Personal checks cannot be accepted. If the information provided below is incomplete, payment will be sent via US Mail. Type of Overnight Delivery. Please check one. Priority Overnight Standard Overnight Saturday Delivery 2nd Day Delivery Overnight Delivery Service: Carrier Account Number ORD 78276A Ed. 11/15 p3 of 5
SECTION 5 SIGNATURES For a Partial Exchange of Assets received or disbursed on or after October 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. Surrender charges, a contract maintenance charge, market value adjustment, taxation, and a 10% federal income tax penalty may apply. Also, any additional amounts (bonuses) credited may be recaptured. Surrenders made from the Market Value Adjustment option before the maturity date are subject to a market value adjustment which may increase or decrease the value of the option, depending on interest rates at the time of surrender. By signing below, I (we): understand and agree to the terms and conditions stated on this form; agree to the request(s) made 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; certify that the tax certification information completed below is correct; and understand that: withdrawal charges, taxation, and a 10% federal income tax penalty may apply; any additional amounts (bonuses) credited may be recaptured; withdrawals may impact the values available under an existing optional benefit; withdrawals made from the Market Value Adjustment option before the maturity date are subject to a market value adjustment which may increase or decrease the value of the option, depending on interest rates at the time of withdrawal; if I am married, and if this request applies to amounts held by a retirement plan described in Sections 401(a) of the IRS Code, then spousal consent and other requirements may apply. If you purchased Non-Qualified Annuity Contracts from Pruco Life or an affiliated company in the same calendar year, they will be considered as one Annuity for tax purposes. If you take a distribution from any of these contracts, the taxable amount of the distribution will be reported to you and the IRS based on the earnings of all such contracts purchased during the same calendar year. 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. I authorize Prudential to initiate credit entries, and if necessary, debit entries and adjustments for any credit entries made in error, to the account and depository named in Section 4 (the Financial Institution ). I/we understand receipt of funds may take up to 2 business days. Note: All parties in interest must sign (e.g. irrevocable beneficiaries). Failure to do so may result in a delay in payment. Additionally, if you are signing on behalf of an individual or entity in the capacity of Attorney-In-Fact or Trustee, the proper authorization must be on file or submitted with this request. (Continued) ORD 78276A Ed. 11/15 p4 of 5
SECTION 5 SIGNATURES (continued) PLACE SIGNATURE GUARANTEE STAMP IN THE BOX (IF APPLICABLE) If you are not a U.S. person (including resident alien) submit the attach applicable IRS Form W-8 (BEN,BEN-E,EXP, ECI, 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). The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding. Contract owner s signature Joint owner s signature (if applicable) Party-In-Interest s signature and designation (if any) IMPORTANT Print Name: If contract is entity owned, a valid Certificate of Entity Ownership form is needed on file for this withdrawal to be processed. If needed, this form can be obtained by calling the Annuities Service Center. Trustee Plan Administrator (choose one) Partner Other Authorized Individual s signature Print Name: (choose one) Trustee Partner Plan Administrator Other Authorized Individual s signature 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 78276A Ed. 11/15 p5 of 5