Request for Required Minimum Distribution (RMD) For the Prudential Defined Income Variable Annuity Variable annuities are issued by Pruco Life Insurance Company (in New York, by Pruco Life Insurance Company of New Jersey) and distributed by Prudential Annuities Distributors, Inc. All are Prudential Financial companies and each is solely responsible for its own financial condition and contractual obligations. Prudential Annuities is a business of Prudential Financial, Inc. Use this form to request the minimum distribution payout from your Individual Retirement Annuity (IRA)/ Simplified Employee Pension (SEP) Plan or 403(b). Please use a separate request form for each annuity contract. Not for use with Non-Lifetime withdrawals. In order to request your RMD amount as a Non-Lifetime withdrawal for Prudential Defined Income (PDI), you must complete the PDI Partial Withdrawal form. 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 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 NO ELECTION Choosing either option will waive RMD. Please proceed to section 7 for signatures. I have chosen to take my RMD payment from another company. This includes Prudential contracts. (Prudential will assume you have chosen this election in future years unless we are notified otherwise.) The Annuity referenced above is a 403(b) Tax Sheltered Annuity (TSA) sponsored by my current employer and therefore I am not required to take a minimum distribution at this time. (Prudential will assume you have chosen this election in future years unless we are notified otherwise.) SECTION 3 TYPE OF REQUEST IMPORTANT For Prudential Defined Income contracts: Multiple systematic distribution programs cannot be active at the same for PDI. If you are currently enrolled in a Systematic Withdrawal program, we will cancel that program before establishing your RMD schedule. Request Option: Terminate Update Existing Program Start New Program SECTION 4 CALCULATION ELECTIONS- PLEASE CHOOSE ONE: A, B, OR C A. Please calculate my RMD using the uniform life table. (Prudential will assume you have chosen this election in future years unless we are notified otherwise.) If no frequency or start date is selected below then we will set up for an annual distribution starting on Dec. 10th of the current year. Date : Please choose a date between the 1st and the 28th. Frequency: Monthly Quarterly Semiannually Annually (Continued) ORD 207378 Ed. 6/17 p1 of 7
SECTION 4 CALCULATION ELECTIONS- PLEASE CHOOSE ONE: A, B, OR C (continued) Only provide a date below if you are electing to receive an April Deferral payment. IMPORTANT April Deferral: YES NO Date : Please choose a date between January 1st and March 28th of the year after you reach 70½. By electing April Deferral, you will receive two RMD checks in the year after you reach 70½. You may wish to consult your tax advisor prior to making this election because neither we nor our representatives can provide tax advice. IMPORTANT In certain instances you must provide us with a December 31st Account Value or an adjustment to your December 31st Account Value in order for us to perform your RMD calculation. If your Prudential annuity did not have a fair market value on 12/31 of the year prior to your minimum distribution year, OR if you transferred/rolled over funds to your Prudential annuity and the funds were not included in the 12/31 fair market value from your previous IRA, 403(b) or other eligible retirement plan, please provide us with the amount of the transfer/rollover or 12/31 fair market value from the previous company. If you took withdrawals from your previous IRA, 403(b), or eligible retirement plan that satisfied a portion of your RMD, please indicate the amount of the withdrawals. B. Please calculate my RMD under the spousal exception to the RMD. I understand that in order to be eligible to have my RMD calculated using the joint life expectancy of myself and my spouse, my spouse must be more than 10 years younger than me and 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). If this option is elected and the client is not eligible for the spousal exception, RMD will be set up based on Option A Uniform Lifetime Table. IMPORTANT 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. This calculation method is only available to federally recognized spouses. You may wish to consult with your tax advisor. Name of Spouse (First, Middle, Last Name) Spouse s Date of Birth Date : Please choose a date between the 1st and the 28th. Select only one Frequency: Monthly Quarterly Semiannually Annually IMPORTANT In certain instances you must provide us with a December 31st Account Value or an adjustment to your December 31st Account Value in order for us to perform your RMD calculation. If your Prudential annuity did not have a fair market value on 12/31 of the year prior to your minimum distribution year, OR if you transferred/rolled over funds to your Prudential annuity and the funds were not included in the 12/31 fair market value from your previous IRA, 403(b) or other eligible retirement plan, please provide us with the amount of the transfer/rollover or 12/31 fair market value from the previous company. If you took withdrawals from your previous IRA, 403(b), or eligible retirement plan that satisfied a portion of your RMD, please indicate the amount of the withdrawals. ORD 207378 Ed. 6/17 p2 of 7
SECTION 4 CALCULATION ELECTIONS- PLEASE CHOOSE ONE: A, B, OR C (continued) C. I have performed my own calculation (one time only): Not for use to elect a Non-Lifetime withdrawal. In order to request your RMD amount as a Non-Lifetime withdrawal, you must complete the Partial Withdrawal form. Not for use with 403b contracts. Please use the request for withdrawal from a 403b form. Please note any amount provided in excess of the RMD calculated by Prudential for this contract may be subject to CDSC and/or excess income. Please see the IMPORTANT NOTICES section for more details. We will process immediately unless otherwise specified. Date : IMPORTANT NOTICES: If you elect to provide your own calculation Any amount in excess of the RMD calculated by Prudential for this contract is subject to all of the terms and conditions of the Annuity, including any applicable CDSC. 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. You should be aware of whether the withdrawal is subject to a CDSC and how the withdrawal could affect the GIA under this benefit. Excess Income Excess Income refers to a withdrawal that (i) exceeds your GIA and (ii) is not a required minimum distribution calculated by Prudential and distributed under a program that we administer. If you take a withdrawal of an Excess Income, it proportionally reduces your GIA and will result in a permanent reduction to your GIA for current and future Annuity Years. If you would like to make an excess withdrawal and are uncertain how Excess Income will reduce your future GIA, then you may contact us prior to requesting the withdrawal to obtain a personalized, transaction-specific calculation showing the effect of Excess Income. Although you are guaranteed the ability to withdraw your Guaranteed Income Amount for life even if your Account Value falls to zero, if that particular withdrawal of Excess Income (described above) brings your Account Value to zero, your Guaranteed Income Amount also would fall to zero, and the benefit and the Annuity then would terminate. In that scenario, no further amount would be payable under the Defined Income Benefit (and the Death Benefit would not be payable upon death). ORD 207378 Ed. 6/17 p3 of 7
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. 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 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 207378 Ed. 6/17 p4 of 7
SECTION 6 PAYMENT AND MAILING INSTRUCTIONS 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 VOIDED CHECK HERE (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. ORD 207378 Ed. 6/17 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) programs in quarterly statements instead of confirming those transactions immediately. By signing below, I (we) acknowledge the following: Excess Income will permanently reduce the GIA available to me in current and future Annuity Years. If I am currently enrolled in a Systematic Withdrawal program, Prudential will cancel that program before establishing my RMD schedule. The Internal Revenue Code requires individuals to receive minimum distributions from their IRAs/SEPs by April 1 of the year following the year they reach age 70½. There will be no waiver of surrender charges or administrative fees applied to withdrawals made from this contract. However, Prudential reserves the right to waive such charges as necessary to comply with state law. Regular IRA contributions cannot be made to the contract in the year in which I reach age 70½ or in any later year. Prudential is required to report the gross distribution amount via Form 1099-R to me and the IRS. If any portion of my account balance is attributable to after-tax or non-deductible contributions, it will be up to me to determine the taxable portion of the distribution. If I have not met the required minimum distribution for the year in which the funds are paid to Prudential, I understand it is my responsibility to remove the minimum distribution from the purchase payment prior to remitting money to Prudential with this application. If I have elected minimum distribution, by signing this form, I acknowledge the following: Each year, Prudential will calculate and notify me of the required distribution amount that applies to this contract. I understand that I am responsible for satisfying the RMD requirement that applies to this contract. I authorize Prudential to send me by the end of each calendar year the amount necessary to meet the minimum distribution requirement that only applies to this contract unless, by the end of November each year, I have: 1) already satisfied my RMD amount that applies to this contract through withdrawals from this contract during the calendar year; 2) notified Prudential that I already have taken the RMD amount that applies to this contract by taking a withdrawal from another eligible source held outside this contract; or 3) notified Prudential that I plan to satisfy the minimum distribution amount by taking a withdrawal from another eligible source held outside this contract before the end of the calendar year. If I notify Prudential under option 2 or 3, I understand that my required minimum distribution program will be terminated until I choose to re-establish it. If a trustee to trustee transfer, direct rollover or roth conversion of the full contract value is requested when there is an active Required Minimum Distribution program running, the Required Minimum Distribution will be removed and sent to the Owner prior to the remaining funds being sent to the transfer institution. Prudential will determine the required minimum distribution based only on amounts held under this contract. It is my responsibility to calculate and receive the total required distributions from all my other IRAs/SEPs/403(b)s, if any. I agree I shall not bring any claim against Prudential in the event I fail to satisfy the minimum distribution amounts required for my IRAs/SEPs/403(b)s held outside this contract. If a variable annuity is requested, the contract will reflect the growth or loss depending upon investment performance. Poor investment performance that results in a decrease in contract value cannot be counted towards the required distribution amount. It may be possible to rollover or transfer other eligible funds to these IRAs/SEPs. However, Prudential cannot calculate or distribute a minimum distribution amount on these contributions in the year in which they are credited to the contract. Prudential will include the amounts in calculating all future minimum distribution amounts in subsequent years. Hereby authorize this withdrawal request. 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. This form, and the information contained within, is not intended as investment advice and is not a recommendation about managing or investing your retirement savings. Neither Prudential Annuities, nor the Prudential entity(ies) set forth on this form, are acting as your fiduciary as defined by any applicable laws and regulations. Please consult with your qualified investment professional about managing or investing your retirement savings. (Continued) ORD 207378 Ed. 6/17 p6 of 7
SECTION 7 SIGNATURES (continued) 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. 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. 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. 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. SIGN HERE Contract owner s signature Date of signature SIGN HERE Party-In-Interest s signature and designation (if any) Date of 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 207378 Ed. 6/17 p7 of 7