Annuity Withdrawal Request for Partial & Full Surrenders 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 request a full surrender, partial withdrawal and Non-Lifetime withdrawal. For 403(b) or Optional Retirement Plan (ORP) withdrawals, the 403(b) Tax Sheltered Annuity or ORP Form MUST be used. Not for use with PruSecure Fixed Indexed Annuity contracts. Instructions: All information must be typed or printed using blue or black ink. Note: Your request cannot be reversed once it has been processed. SECTION 1 OWNER 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) 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 TYPE OF WITHDRAWAL FULL SURRENDER PARTIAL SURRENDER Any Systematic Withdrawal program scheduled for less than or equal to the Annual Income Amount (AIA) or Protected Annual Withdrawal Amount (PAWA, for Guaranteed Minimum Withdrawal Benefit (GMWB)) or equal to the Annual Withdrawal Amount (AWA, for Lifetime Five (LT5)) will be cancelled if a partial withdrawal is requested and the combination of the partial withdrawal and systematic withdrawal program now results in you exceeding your AIA, PAWA, or AWA for the current year. Any Systematic Withdrawal program scheduled for greater than your AIA, PAWA (for GMWB) or AWA (for LT5) will not be cancelled if a partial withdrawal request is processed. I wish to withdraw: $ Charge Free amount available Withdrawal Type: Please elect the appropriate box below. If no election is made, your request will be processed as a Lifetime Withdrawal. If you choose the Non-Lifetime Withdrawal option and it is not available on your contract, we will process as a Lifetime Withdrawal. If electing a Lifetime Withdrawal or Non-Lifetime withdrawal, you must specify a dollar amount. Non-Lifetime Withdrawals are only available to contract owners with the following Optional Living Benefit suites: Highest Daily Lifetime 7 Plus (HD7 Plus), Highest Daily Lifetime 6 Plus (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). Non-Lifetime Withdrawal This withdrawal will not establish your initial AIA. It is a one-time withdrawal offered as an optional feature of the benefit. This withdrawal is available only at the time of your first withdrawal. Once processed, it may not be reversed. Requesting this withdrawal will proportionally 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. Lifetime Withdrawal This withdrawal will establish your initial AIA under the optional benefit. Once processed, it may not be reversed. Please refer to the prospectus for further details. (Continued) ORD 310003 Ed. 2/18 p1 of 7
SECTION 2 TYPE OF WITHDRAWAL (continued) IMPORTANT: If the amount you intend to withdraw will reduce your Account Value to less than its required minimum balance, then we will instead withdraw the maximum amount allowable. If your Account Value is less than the required minimum balance at the time of your request, we will be unable to process this withdrawal. This withdrawal is a removal of excess IRA contribution(s) in the amount of $ Remove funds from (Check one.) Current year Previous year Two years or more (Tax Year) This distribution will be taken NET of taxes and any applicable contingent deferred sales charges. Withdrawal amount may include any earnings and losses. To have this processed as a non-lifetime withdrawal please indicate above. 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 (CDSC). By checking this box, you authorize Prudential to process this request as of the contract anniversary and not the date it is received. Elections greater than your AIA, AWA (for LT5), or PAWA (for GMWB) will result in excess withdrawals. 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 Charge (CDSC) and/or federal and state taxes will be deducted from the contract value, this may cause a withdrawal in excess of the AIA, AWA or PAWA (for GMWB).) Gross amount (Check will be for the amount indicated above, less any applicable Contingent Deferred Sales Charge (CDSC) and/or federal and state taxes.) IMPORTANT NOTICES: Any Systematic Withdrawal program scheduled for less than or equal to the AIA or PAWA (for GMWB) or equal to the AWA (for LT5) will be cancelled if a partial withdrawal is requested and the combination of the partial withdrawal and systematic withdrawal schedule now results in you exceeding your AIA, PAWA, or AWA for the current year. Any Systematic Withdrawal program scheduled for greater than your AIA, PAWA (for GMWB) or AWA (for LT5) will not be cancelled if a partial withdrawal request is processed. 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, or HDI, HDI 2.0, HDI v2.1, or HDI v3.0 benefit suites: 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. If a post-withdrawal step up occurs and you wish to withdraw the higher AIA through a Systematic Withdrawal program, you must either complete a new Systematic Withdrawal form or call our Annuities Service Center. 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. You may change your systematic withdrawal or cancel enrollment at any time by submitting a new form or by calling our Annuities Service Center. Please note that we may discontinue the enrollment feature if the contract fund falls below the contractual minimum. The contract fund may fall below the minimum due to fund performance or a systematic withdrawal distribution. We will notify you if your withdrawal request is less than the minimum withdrawal allowed. Excess Withdrawals An excess withdrawal refers to a withdrawal that (i) causes cumulative withdrawals in the Annuity Year to exceed your AIA and (ii) is not a required minimum distribution calculated by Prudential. If you take an excess withdrawal, it proportionally reduces your AIA and will result in a permanent reduction to your AIA available in current and future Annuity Years. Additionally, for LT5 an excess withdrawal that exceeds your AWA will proportionally reduce your AWA and will result in a permanent reduction to your AWA available in current and future Annuity Years. Cumulative withdrawals in an Annuity Year that exceed the AWA 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. (Continued) ORD 310003 Ed. 2/18 p2 of 7
IMPORTANT NOTICES (continued): GMWB: Cumulative withdrawals (including applicable CDSC and/or MVA) in any Annuity Year that exceed the PAWA trigger a proportional adjustment to both the Protected Value and PAWA. Additionally, if you take a withdrawal in excess of your PAWA it will result in a permanent reduction to your PAWA for current and future Annuity Years. 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, AWA, or PAWA. If the combination of the requested partial withdrawal and your systematic withdrawal program will result in you exceeding your AIA, AWA (for LT5) or PAWA (for GMWB) for the current year, your systematic withdrawal program will be cancelled. In addition, each systematic withdrawal you take that is an excess withdrawal will proportionally reduce your AIA, AWA (for LT5) or PAWA (for GMWB) and will further reduce the value of your benefit, including a permanent reduction to your AIA, AWA (for LT5) or PAWA (for GMWB) available in current and future Annuity Years. Please monitor your AIA, AWA (for LT5) or PAWA (for GMWB) 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, PAWA for GMWB) 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 (excluding GMWB). 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, AWA (for LT5) or PAWA (for GMWB) under this benefit. If your withdrawal exceeds the AIA, AWA (for LT5) or PAWA (for GMWB), it may be subject to a CDSC. 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, AWA (for LT5) or PAWA (for GMWB). In that scenario, the withdrawal would be deemed Excess Income - thereby resulting in a permanent reduction to the AIA, AWA (for LT5) or PAWA (for GMWB) available to you in current and future years. 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 homebuyer 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 IRC Section 408(d)(3)(B), applies on an aggregate basis to all IRAs (Traditional IRA, SEP IRA, SIMPLE IRA and Roth IRA) owned by an individual, regardless of institution. This is based on a Tax Court ruling in Bobrow v. Commissioner, detailed in Announcement 2014-15 by the IRS. This 12 month limit does not apply to IRA to IRA transfers. Please consult your tax advisor. Rollovers made during or after the year in which the owner turns age 70 1/2, cannot be made from assets representing a required minimum distribution from an IRA, 403(b) or 401(a). 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. If you purchased Non-Qualified Annuity Contracts from Prudential 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. ORD 310003 Ed. 2/18 p3 of 7
SECTION 3 DESIGNATED INVESTMENT OPTION Specify the investment option(s) from which you would like the withdrawal processed. If you do not, a withdrawal will be made proportionately from all current investment option(s). Please note that if you are participating in any optional living benefits excluding Lifetime Five and GMWB, withdrawals must be taken from your Account Value on a pro rata basis from the Investment Options at the time we process each withdrawal. Percentages must total 100%. Investment Allocation Percentage (%) Investment Allocation Percentage (%) % % % % SECTION 4 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. I also certify that if at some point I no longer meet this definition, I will notify Prudential in writing at the address listed on this form. If this box is not checked a premature/normal distribution based on age will be reported. 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. 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. Your withdrawal may also be subject to State income tax withholding in certain states. If your resident State requires mandatory withholding, we will withhold the default amount your State requires even if you elect no withholding. 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: For 401(a) The eligible rollover portion of your distribution is subject to a mandatory 20% federal income tax withholding unless directly rolled to traditional IRA, Roth IRA, a 457(governmental), or another plan qualified under Internal Revenue Code section 401(a). 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. 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 310003 Ed. 2/18 p4 of 7
SECTION 6 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. 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.) 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 310003 Ed. 2/18 p5 of 7
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) / 72(q) programs, auto rebalancing, and Dollar Cost Averaging in quarterly statements instead of confirming those transactions immediately. By signing below, I (we) acknowledge that: Excess withdrawals will permanently reduce the AIA, AWA (for LT5) or PAWA (for GMWB) available to me in current and future Annuity Years; Any Systematic Withdrawal program scheduled for less than or equal to the AIA or PAWA (for GMWB) or equal to the AWA (for LT5) will be cancelled if a partial withdrawal is requested and the combination of the partial withdrawal and systematic withdrawal program now results in you exceeding your AIA, PAWA, or AWA for the current year; Any Systematic Withdrawal program scheduled for greater than your AIA, AWA (for LT5) or PAWA (for GMWB) will not be cancelled if a partial withdrawal request is processed; Withdrawal charges, surrender charges, taxation, market value adjustment and a 10% federal income tax penalty for premature distributions may apply; Any additional amounts (bonuses) credited may be recaptured; Partial withdrawals may impact the values available under an existing optional benefit; 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 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 Beneficiary Income Option (BIO) and its spousal version) will also be reduced to zero and the death benefit will not be payable. 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. 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. There may be tax implications as a result of this request(s), including requests to pay advisory fees, and the request(s), including requests to pay advisory fees, (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. 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. 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. This full or partial surrender discharges Prudential from further obligation to pay future benefits to the extent that the Annuity Contract Value is reduced by this withdrawal. IMPORTANT: I understand that if I have an active 72(t)/(q) program on this account, that the program will be terminated prior to processing this withdrawal request, and that the termination may result in the retroactive application of the 10% early withdrawal penalty. I understand that Prudential 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. 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. (Continued) ORD 310003 Ed. 2/18 p6 of 7
SECTION 7 SIGNATURES (continued) PLACE SIGNATURE GUARANTEE STAMP IN THE BOX (IF APPLICABLE) 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 (BEN, BEN-E, ECI, EXP or IMY). 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. 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. (choose one) Trustee Partner Plan Administrator 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 310003 Ed. 2/18 p7 of 7