Request for Substantially Equal Periodic Payments Under IRC Section 72(t)

Request for Substantially Equal Periodic Payments Under IRC Section 72(t) Annuities are issued by Pruco Life Insurance Company, Pruco Life Insurance Company of New Jersey, the Prudential Insurance Company of America (PICA) and Prudential Annuities Life Assurance Corporation (PALAC) (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 establish a schedule of periodic payments under Internal Revenue Code (IRC) Section 72(t). Distributions under this program must meet the product minimums, please refer to your prospectus for details. Not for use with PruSecure Fixed Indexed Annuity contracts. Not available for Non-Resident Aliens. Not for use with Beneficiary Annuity contracts. Instructions: All information must be typed or printed using blue or black ink. SECTION 1 OWNER INFORMATION Annuity Number E-mail Address Owner Name (First, Middle, Last Name) Telephone Number Mobile Number 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 PAYMENT METHOD If you would like your 72(t) payment based on your Annual Income Amount (AIA), Annual Withdrawal Amount (AWA, for Lifetime Five (LT5)) or Protected Annual Withdrawal Amount (PAWA, for Guaranteed Minimum Withdrawal Benefit (GMWB)) please complete section C. Elections of a 72(t) program where the calculation method results in an excess withdrawal (exceeding your AIA, AWA, or PAWA) are not permitted. A. New 72(t) Program Calculate my 72(t) payment using the following calculation method. (Please check one.) Required Minimum Distribution (RMD) Important Note: For the RMD method we will recalculate your future distributions on an annual basis on December 31 of each year, using the account balance on that date. Please provide the December 31 fair market value for the previous year Please provide the life expectancy table used for the calculation. Uniform Life Expectancy Table Single Life Expectancy Table Joint Life Spouse s date of birth (Month / Day / Year) My spouse must be more than 10 years younger than me and my spouse must be the sole primary beneficiary of my annuity for the entire year to which my distribution applies (certain exceptions apply if your spouse dies during the year or you become divorced). (Continued) ORD 310006 Ed. 1/18 p1 of 8

SECTION 2 PAYMENT METHOD (continued) Amortization Uniform Life Expectancy Table Single Life Expectancy Table Joint Life Spouse s date of birth (Month / Day / Year) My spouse must be more than 10 years younger than me and my spouse must be the sole primary beneficiary of my annuity for the entire year to which my distribution applies (certain exceptions apply if your spouse dies during the year or you become divorced). Annuitization (Annuity Table) B. Continuation of an Existing 72(t) Program From Your Previous Carrier I would like to continue a 72(t) program that I began at another carrier. Date of my first payment at the other carrier* (Month / Day / Year) Annual distribution amount $ Continuation of an existing 72(t) program from your previous carrier for an amount greater than your AIA will result in excess withdrawals. *Only programs begun prior to 1/1/03 will be reported as an exception to the 10% tax penalty under section 72(t). Due to changes under Revenue Ruling 2002-62, if your program began after 1/1/03, Prudential will not be able to determine if your program qualifies for an exception. In this case, we will set up your request as a Systematic Withdrawal program and the distribution will be recorded as a premature distribution. In either case, it is the responsibility of the taxpayer to ensure that the stream of payments qualifies as an exception under section 72(t). Please indicate the method you used to calculate your 72(t) payments: Amortization Annuitization Required Minimum Distribution (RMD) Please provide the December 31 fair market value for the previous year $ Please provide the life expectancy table used for the calculation: Uniform life expectancy table Single life expectancy table Joint life expectancy table C. New 72(t) Program Based on Your Living Benefit For Contracts with the Lifetime Five benefit suite (LT5), Highest Daily Lifetime Five (HD5), Highest Daily Lifetime Seven benefit suite (HD7), Highest Daily Lifetime 7 Plus benefit suite (HD7 Plus), Highest Daily Lifetime 6 Plus benefit suite (HD6 Plus), Highest Daily Lifetime Income (HDI), Highest Daily Lifetime Income 2.0 (HDI 2.0), Highest Daily Lifetime Income v2.1 (HDI v2.1), Highest Daily Lifetime Income v3.0 (HDI v3.0) suite of benefits, or Guaranteed Minimum Withdrawal benefit (GMWB): Calculate my new 72(t) payment using one of the following: Withdrawals based on the current Annual Income Amount Your withdrawal amount will be calculated based on the LT5 benefit suite, HD5, HD7 benefit suite, HD7 Plus benefit suite or HD6 Plus benefit suite, current Annual Income Amount. Withdrawals based on the current Annual Withdrawal Amount (Only available with LT5 benefit suite) Your withdrawal amount will be calculated based on the current LT5 Annual Withdrawal Amount, initially equal to 7% of the initial Protected Withdrawal Value. The contract must have a PWV greater than zero to take an AWA withdrawal. Withdrawals based on current Protected Annual Withdrawal Amount (only available with GMWB) - Your withdrawal amount will be calculated based on the current Protected Annual Withdrawal Amount (PAWA), initially equal to 7% of the initial Protected Value. The contract must have a Protected Value (PV) greater than zero to take a PAWA withdrawal. If you choose withdrawals based on the current Annual Income Amount, the current Annual Withdrawal Amount (only available with the Lifetime 5 suite of benefits) or the current Protected Annual Withdrawal Amount (only available with GMWB) the payment must be made in accordance with an approved calculation method. If the approved calculation method returns an amount that does not support your AIA, AWA (for LT5) or PAWA (for GMWB) then the 72(t) program will not be established. (Continued) ORD 310006 Ed. 1/18 p2 of 8

SECTION 2 PAYMENT METHOD (continued) D. Conversion of Existing 72(t) Program to the RMD (Life Expectancy) Method. If you select this option and have one of the benefits referenced in Section C, please note, if the calculation returns an amount greater than your AIA, AWA (for LT5), or PAWA (for GMWB) the 72(t) program will not be changed. If you choose to convert to the Life Expectancy method, the uniform table will be used to determine your life expectancy unless you check the single life expectancy box or joint life box. Note: The stream of payments calculated using the joint life are smaller than the income stream calculated by using the uniform life expectancy or single life expectancy tables. In addition we will recalculate your future distributions on an annual basis on December 31st of each year using the account balance on that date. I am requesting a conversion of an existing Prudential 72(t) program to the RMD method. I am requesting a conversion of a program that began at another carrier to the RMD method at Prudential. Please provide, the December 31 fair market value for the previous year if funds were not held at Prudential at this time. Fair market value (if applicable) $ Please provide the life expectancy table used for the calculation Uniform life expectancy table Single life expectancy table Joint Life Spouse s date of birth (Month / Day / Year) My spouse must be more than 10 years younger than me and my spouse must be the sole primary beneficiary of my annuity for the entire year to which my distribution applies (certain exceptions apply if your spouse dies during the year or you become divorced). Date my first payment was processed using my original calculation method Month Day Year Important Note: If the first payment under your original calculation method was processed prior to January 1, 2003, you are permitted to convert to the Life Expectancy method at any time. If your first payment was processed on or after January 1, 2003, you may not convert to life expectancy method in the year you started a 72(t) payment stream under another method. You may choose to convert to the life expectancy method at any time after the beginning of the year following the year of election. SECTION 3 START DATE Please process my first 72(t) program payment (Month / Day / Year). If multiple premiums are expected, you should not submit this form until we have received the final premium. If any prior withdrawals would cause this 72(t) program to be set up in excess of the AIA, or AWA (for LT5) or PAWA (for GMWB), the program will not be established. SECTION 4 FREQUENCY Please select one of the payment frequencies listed below. Note: The frequency cannot be changed once the program has started. Monthly Quarterly Semiannually Annually ORD 310006 Ed. 1/18 p3 of 8

IMPORTANT NOTICES: For GMWB, the Protected Value is determined as of the date you make your first withdrawal under your Annuity following your election of the benefit. 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. 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 Contingent Deferred Sales Charge (CDSC) and Market Value Adjustment (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 prorata, 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. Please refer to your current prospectus for further details. The rules related to 72(t) program are very complex. Please read all of the information on this form and consult with your tax advisor before proceeding. Section 72(t) of the IRC imposes a 10% penalty tax on distributions made before age 59½ from qualified retirement plans. IRC 72(t) relates to Individual Retirement Accounts (IRA) 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), the distributions must: 1. Continue unaltered for the longer of 5 years or until the owner reaches age 59½, and 2. Be based on the life or life expectancy of the owner, or joint lives or joint life expectancies of owner and designated beneficiary, and 3. Be made at least annually (i.e., annually, semiannually, quarterly, monthly). Distributions under this program must meet the minimum withdrawal amounts and the minimum amounts that must remain in your contract after the withdrawal. Payments may be subject to a CDSC, if applicable, under the terms of your annuity contract. Payments from Fixed Allocations may be subject to a MVA and are not limited to accrued earnings. To ensure equal payments, liquidations from your account will be adjusted to offset any CDSC or MVA. For variable annuity contracts, account values are not guaranteed and are subject to market fluctuation. Investment results may be more or less than anticipated. Election of an IRC Section 72(t) distribution will reduce account value by the amount disbursed as long as the distribution stream is in place. While your 72(t) program is in effect, no additional contributions can be made to your annuity contract after your 72(t) withdrawals begin or after the date you have chosen to value your annuity, if earlier. ORD 310006 Ed. 1/18 p4 of 8

SECTION 5 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. This election will remain in effect until you revoke it. You may change your withholding election on future payments by notifying us. 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 310006 Ed. 1/18 p5 of 8

SECTION 6 PAYMENT AND MAILING 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. Note: Payments made via EFT/ACH to a party other than the owner are not permitted. Bank Name Bank account number Bank telephone number ABA routing number (To ensure accuracy, verify with your bank.) Type of Account Checking Savings Name of Depositor on bank records (first, middle initial, last name) 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. 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 7. Please enter special payee s name and address below.) 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. Please allow 3-5 days from the processing date to receive your funds by U.S. First Class Mail. Name of special payee if selected above Street City State ZIP Code Country ORD 310006 Ed. 1/18 p6 of 8

SECTION 7 SIGNATURES TRANSACTION CONFIRMATIONS We may confirm regularly scheduled transactions, including, but not limited to, the Annual Maintenance Fee, electronic fund transfer, Systematic Withdrawal/ Required Minimum Distribution / 72(t) programs, auto rebalancing, and Dollar Cost Averaging in quarterly statements instead of confirming those transactions immediately. By signing below, I acknowledege that: For Federal tax purposes, the term spouse includes any individuals who are lawfully married under state law. Federal law does not recognize domestic partnerships or civil unions that are not designated as married under state law. If my Account Value is reduced to zero as a result of withdrawals, the death benefit (not including HD7 with Beneficiary Income Option (BIO) and its spousal version and HD7 Plus with BIO and its spousal version) will also be reduced to zero and the death benefit will not be payable. All information provided is accurate. I understand that the amount that must be paid in order to qualify as a substantially equal periodic payment is based upon Prudential s understanding of the applicable tax law. I also understand that I am responsible for consulting with my own tax advisor regarding whether this amount satisfies the substantially equal periodic payment rules in Internal Revenue Code Section 72(t), and is therefore excepted from the 10% federal income tax penalty applicable to certain premature distributions from an annuity contract. 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(s) on which the distributions are made, provided that the total number of payments for the year and the total annual payment amount does not change. If a partial surrender or a full surrender is processed after a 72(t) stream of payments has been established, then the 72(t) schedule is terminated and the prior payments will be treated as regular distributions. Prudential will only report payments as excepted from the 10% federal income tax penalty if no changes other than the ones described above are made. I agree to hold Prudential harmless in the event that I choose to initiate a transaction other than those specified above and/or an Internal Revenue Service (IRS) or other third-party inquiry should result in the determination that I am not eligible to receive substantially equal periodic payments. In such case, I agree to notify Prudential of this determination promptly and in writing. I understand that I must still adhere to and abide by my annuity contract obligations, including, but not limited to, applicable charges and fees. I authorize Prudential to surrender my contract to protect my 72(t) stream in the event that this becomes necessary. Prudential does not provide tax or legal advice, and has provided me with a calculation of a substantially equal periodic payment amount based on their understanding of tax law. Prudential expressly disclaims responsibility for the accuracy of the substantially equal periodic payment amount provided. To the extent desired, I have consulted with my accountant, tax advisor, and/or legal advisor regarding the substantially equal periodic payment amount applicable to me. If the amount I intend to withdraw will reduce my contract value to less that its required minimum balance, then Prudential will instead withdraw the maximum amount allowable. If your contract value is less than the required minimum balance at the time of my request, Prudential will be unable to process this withdrawal. 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 6 (the Financial Institution ). I/we understand receipt of funds may take up to 2 business days. 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. If you are enrolled in any optional living benefits and/or optional death benefits, please bear in mind that withdrawals from your Annuity may impact the benefits and/or associated values provided under such programs. Please refer to your contract and prospectus for further information or contact your financial professional with any questions. 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. (Continued) ORD 310006 Ed. 1/18 p7 of 8

SECTION 7 SIGNATURES (continued) PLACE SIGNATURE GUARANTEE STAMP IN THE BOX (IF APPLICABLE) 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. OWNER S TAX CERTIFICATION (Substitute Form W-9) - To be completed only by U.S. persons (including U.S. citizens and resident aliens). If not a U.S. person, you are required to submit the applicable IRS Form W-8 series. Social Security Number or Employer Identification Number Under penalties of perjury, I certify that the taxpayer identification number listed on this form is my correct SSN/EIN and I am a U.S. citizen or other U.S. person (including resident aliens). I further certify that I am exempt from backup withholding and/or FATCA reporting unless I check the applicable box(es) below: I have been notified by the Internal Revenue Service that I am subject to backup withholding due to the failure to report all interest or 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. SIGN HERE Contract owner s signature Date of signature (Month / Day / Year) SIGN HERE Party-In-Interest s signature and designation (if any) Date of signature (Month / Day / Year) This form, and the information contained within, does not take into account the investment objectives or financial situation of any client or prospective clients. The information is not intended as investment advice and is not a recommendation about managing or investing your retirement savings. Clients seeking information regarding their particular investment needs should contact a financial professional. 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 310006 Ed. 1/18 p8 of 8