Prudential Mutual Fund Services LLC a Prudential Financial company Transfer/Direct Rollover/ Conversion Form (Qualified Accounts Only) For assistance: Clients: (800) 225-1852 Financial Professionals: (888) 778-5471 Pruco Financial Professionals: (800) 542-7117 What to do to submit your Transfer of Asset request: 1. Decide You can use this form to request these types of transfers: Transfer of Assets If you want to liquidate and transfer the account proceeds from another custodian to PMFS, complete section 3 and the other sections that apply to your request. Transfer-in-Kind If you want to transfer existing Prudential mutual funds and change the custodian to Prudential Trust Company, complete section 4 and the other sections that apply to your request. 2. Complete Read the attached instructions carefully before completing this form. Please provide all requested information in each section to ensure your request is processed in a timely manner. 3. Return Send us your completed form. Return form to: Regular mail Prudential Mutual Fund Services LLC P.O. Box 9658 Providence, RI 02940 Express mail Prudential Mutual Fund Services LLC 4400 Computer Drive Westborough, MA 01581
1. About You (Please attach only one account type.) If this is for a new Prudential account, you can leave the account number field below blank. PMFS account number Social Security number First name Middle initial Last name Entity name (if applicable) Street Address City State ZIP Code Home phone Mobile phone Email address 2. About the Account You are Transferring to PMFS A. Account types being transferred to PMFS Traditional IRA Roth IRA SEP-IRA 403(b) Plan Governmental 457 Plan Roth 401(k) Plan SIMPLE IRA Inherited IRA Employer-Sponsored 401(a) Retirement Plan (i.e., 401(k), pension or profit sharing plan, or defined benefit plan) B. Resigning Custodian Information Name of institution/employer-sponsored retirement plan Attention Street address City State ZIP Code Contact name C. Account number(s) to be transferred Contact phone Account number Account number Account number MF1012 Ed. 6/2017 page 1 of 7
3. Transfer of Assets All liquidations are done immediately unless special instructions are provided below. A. Liquidate All $ (estimated value) Partial % or $ B. Special instructions for CDs and certain annuity contracts Transfer immediately. I am aware of and acknowledge any penalty I may incur from an early withdrawal. Transfer at maturity (month, day, year): / / (Please submit 4 weeks prior to maturity date.) 4. Transfer-in-Kind Complete this section only if you have existing Prudential mutual funds and want to change your current Trustee/ Custodian. Transfer my funds in kind immediately. All Partial $ 5. PMFS Account Type The transferred proceeds will be invested into the following account type. Traditional IRA, Rollover IRA, or SEP IRA Roth IRA or Roth Conversion IRA Establishment date* Inherited IRA 403(b) Plan You must have an existing account at PMFS. New accounts will not be accepted. * The date you originally contributed to a Roth IRA or converted from a traditional IRA to a Roth IRA. This information is required by the IRS for compliance with the 5 tax-year holding period requirement. MF1012 Ed. 6/2017 page 2 of 7
6. Mutual Fund Selection and Allocation I am opening a new account and have attached a completed application. Allocation instructions are included in section 4 of my new account application. For this transfer request, invest the amount received into my existing account(s) (indicated in section 1) in the funds and allocations listed below. Note: All allocations by percentage must total 100%. Fund Name Fund Number Share Class Percent or Amount 7. Tax Withholding Election and Roth Conversion Disclosure Indicate what percentage, if any, we should withhold for federal and state income tax purposes. If you do not want taxes withheld, proceed to the next section. If you would like to have taxes withheld, please check the box below: I would like federal and applicable state income taxes withheld from my IRA distribution being converted to a Roth IRA. I understand that, as a result, the portion of my IRA distribution that is withheld as income taxes will not be converted to my Roth IRA and may result in adverse tax consequences. If you would like more than 10% withheld, please indicate below: Federal taxes Percentage: Dollar amount % (minimum 10% distribution), or $ (Cannot be less than 10% of distribution.) State taxes* (Percentage or Dollars) Percentage: %, or Dollar amount $ *Percentage/dollar amount cannot be less than the minimum required for your state. MF1012 Ed. 6/2017 page 3 of 7
8. Authorization For Traditional IRAs, Roth IRAs, SEP-IRAs, and 403(b) accounts. It is my intention to effect a transfer, without inclusion of the amount to be transferred in my gross income. You are directed to transfer all or a portion of the redemption value of the account as identified in section 2 to an account established for me with Prudential Trust Company (PTC) as custodian. Accordingly, you are hereby directed to request on my behalf the transfer of my interest in the account referenced in section 2 for subsequent investment in Prudential Mutual Funds for investment in the custodial account(s) maintained for me. I hereby agree to the terms and conditions set forth in this Transfer/Direct Rollover/Conversion Authorization. For direct rollover. This authorizes the employer-sponsored retirement plan designated in section 2 to distribute my eligible rollover distribution directly from my retirement plan to PTC in accordance with the instructions in section 3. I have received and considered a copy of The Should You Rollover Your Retirement Plan? Challenge for applicable IRA rollovers. I understand that the conversion of a traditional IRA to a Roth IRA will result in a taxable event which will be reported to the IRS. If the account owner has attained the age of 70½ or older in the year of this transfer request, the required minimum distribution must be removed prior to the transfer being made. I understand that the resigning custodian may charge a closeout fee for IRA accounts. The default election is for the Resigning Custodian to redeem shares to cover charges. I authorize the resigning custodian to redeem shares to cover those charges. I will arrange to cover those charges by other means. Important: If elected, any fees must be paid to the resigning custodian prior to submitting this form, or they may deny the request. X Account owner s signature Date (mm/dd/yyyy) Important: If you are acting on behalf of the account owner, please indicate the capacity in which you are acting by checking the appropriate box below. If the correct box is not listed, please check Other and specify your capacity. Appointee under POA Other, please specify Place medallion signature guarantee here 9. Prudential Trust Company s Acceptance (To be completed by PMFS.) Prudential Mutual Fund Services LLC, as agent for the Prudential Trust Company (PTC) which is custodian of the traditional IRA, Roth IRA, SEP IRA or 403(b) plan, hereby confirms its acceptance of the above mentioned transfer or rollover. Authorized signature of Prudential Mutual Fund Services LLC (as agent for PTC) X MF1012 Ed. 6/2017 page 4 of 7
10. Financial Professional Identification and Signature (if applicable) Financial professional s name (first name, MI, last name) (Please print.) Financial professional s signature X Broker/Dealer s name (Please print.) Broker/Dealer number Branch/Agency number Rep./Contract number Branch telephone number Alternate telephone number MF1012 Ed. 6/2017 page 5 of 7
Prudential Mutual Fund Services LLC a Prudential Financial company Instructions & Disclosures For assistance: Clients: (800) 225-1852 Pruco Financial Professionals: (800) 542-7117 Financial Professionals: (888) 778-5471 About You Use this form to request a transfer of assets or transfer in kind from another custodian to Prudential Mutual Fund Services LLC (PMFS). Complete a separate transfer form for each sending institution. Include a copy of your most recent account statement with this form. Note: Prudential Mutual Fund Services LLC cannot accept stock certificates. Once we receive your transfer request and confirm that it is in good order, we will send a letter of acceptance to your current custodian requesting that the assets be sent to PMFS. Please follow up with your current custodian to determine the time frame for transferring your account to PMFS. Also, check with the resigning custodian about any financial penalties, suspensions, medallion signature guarantee, federal and state tax withholding elections or other restrictions that could affect the account proceeds that are being transferred to PMFS. If the account you are liquidating is subject to federal and state tax withholdings, then we suggest that you attach a letter of instruction to provide your withholding election for the resigning custodian. About the Account You are Transferring to PMFS Indicate the type of account and account number that you currently own which you would like the resigning custodian to liquidate or transfer to PMFS. Also, provide the name and address of the financial institution or employer-sponsored retirement plan from which the account will be liquidated or transferred. Transfer of Assets This section must only be completed if you own assets (other than Prudential Mutual Funds) and you want the proceeds to be liquidated and transferred to PMFS. Also, indicate any special instructions about when your account at the resigning custodian should be liquidated. Transfer-in-Kind This section should only be completed if you own existing Prudential mutual funds and want to change your current Trustee/Custodian to PMFS. If you own shares of Prudential mutual funds, those shares will not be liquidated. PMFS Account Type State the type of account you want the proceeds to be invested in at PMFS. MF1012 Ed. 6/2017 page 6 of 7
Mutual Fund Selection and Allocation If you are opening a new account, attach a completed IRA Application and we will follow the allocation instructions indicated on your IRA Application. You do not need to provide separate allocation instructions in this section of this form. If the transfer proceeds will be invested into an existing account, indicate in this section the fund(s) and the amount that should be allocated to each fund. Note: All allocations by percentage must total 100%. Refer to the fund s prospectus for the fund minimum and other important information about the fund(s) you have selected. Tax Withholding Election and Roth Conversion Disclosure Federal tax law requires income tax to be withheld at a rate of 10% from the total amount of your IRA distribution or conversion proceeds unless you elect not to have tax withheld. Depending on your state of residence, state tax withholding may also apply. Please consult with your tax advisor regarding the tax consequences of your distribution. Authorization Some resigning custodians require a medallion signature guarantee in order to transfer your account proceeds to PMFS. Please have your signature medallion guaranteed in this section if your current custodian requires a medallion signature. MF1012 Ed. 6/2017 page 7 of 7