Fixed Annuitization Form

Fixed Annuitization Form Annuities are issued by Prudential Annuities Life Assurance Corporation, located in Shelton, CT (main office), a Prudential Financial, Inc. company, which is solely responsible for its own financial condition and contractual obligations. The Rock Prudential Logo is a registered service mark of The Prudential Insurance Company of America and its affiliates. Use this form to annuitize your PALAC deferred annuity or to establish a fixed settlement agreement (for beneficiaries of a PALAC contract). Complete all pages with the original signature(s) of all pertinent parties. If you are eligible and want to elect Required Minimum Distribution payments in lieu of Annuitization, please complete the Request for Required Minimum Distribution form. Instructions: All information must be typed or printed using blue or black ink. SECTION 1 OWNER INFORMATION Current Deferred Annuity Contract Number Owner Name (First, Middle, Last Name) Sex: M F Date of Birth Social Security Number/TIN Owner address required, if contract owner s address of record is a PO Box, please provide a U.S. street address. Joint Owner Name (First, Middle, Last Name) Sex: M F Date of Birth Social Security Number/TIN If we require additional information to complete this request, please indicate who Prudential should contact: Owner Financial Professional SECTION 2 CHANGE ANNUITIZATION DATE If you wish to mature this Contract and the Annuitization date is within 90 days of Prudential receiving this form in good order we will keep the current Annuitization date, unless we are notified in this Section to change. If your Annuitization date is outside 90 days of Prudential receiving this form we will move the Annuitization date to the next available date per your Contract, unless we are notified in this Section to change. If you do not wish to mature this Contract, please complete Section 2 and go to Section 12. (Please refer to your Contract/ Prospectus regarding the Maximum Annuitization date allowed under your Contract.) Request that the Annuitization date be changed to (Check one.) Maximum Annuitization date Other Annuitization date (Month / Day / Year) ORD 04136 Ed. 3/18 p1 of 8

SECTION 3 KEY LIFE/ANNUITANT INFORMATION If other than owner Key Life/Annuitant Name (First, Middle, Last Name) Sex M F Date of Birth Social Security Number Complete the following only if Joint and Survivor Life Annuity option is selected from Section 4 and 7. Joint Key Life/Annuitant Name (First, Middle, Last Name) Sex M F Date of Birth Social Security Number SECTION 4 PAYMENT DATA Choose only one: (when electing a certain period, the length of the period cannot exceed life expectancy. Please Note: if the contract annuitizes and there is an active living benefit on the contract that benefit will terminate.) If the certain period selected does not comply with IRS minimum distribution requirements, the company may reduce the certain period to one that meets the IRS requirements. Life Annuity Payments for life with no certain period. All payments stop with the key life/annuitant s death, whenever that occurs. Fixed Period Annuity (Certain Period Only) Payments for a fixed period as specified below. If the annuitant were to die before the end of this specified period, the remaining payments will continue to the named beneficiary in Section 5. If elected, we may pay the present value of the remaining certain period payments to the named beneficiary in Section 5. 5 years 10 years 15 years 20 years Other Life Annuity with a Certain Period Payments for life with a period certain of (check one): Note: Do not use this check box to select payments for a specified period only (Certain Period only). Please use the Fixed Period Annuity (Certain Period Only) check box above. 5 years 10 years 15 years 20 years Other If the key life/annuitant were to die before the end of this specified period, the remaining certain period payments will continue to the named beneficiary in Section 5. If elected, we may pay the present value of the remaining certain period payments to the named beneficiary in Section 5. Life Annuity for the Annual Income Amount (for contracts with Lifetime Five, Spousal Lifetime Five, Highest Daily Lifetime Five, Highest Daily Lifetime Seven*, Spousal Highest Daily Lifetime Seven*, Highest Daily Lifetime 7 Plus*, Spousal Highest Daily Lifetime 7 Plus*, Highest Daily Lifetime 6 Plus** or Spousal Highest Daily Lifetime 6 Plus Optional Living Benefit.) * Including any applicable elections with the Beneficiary Income Option (BIO) or Lifetime Income Accelerator (LIA). With respect to HD7 with Lifetime Income Accelerator or HD7 Plus with Lifetime Income Accelerator, if you annuitize prior to the 10th benefit anniversary, you cannot become eligible to receive the Lifetime Income Accelerator amount in the future. **Including any applicable elections with the Lifetime Income Accelerator. With respect to HD6 Plus with Lifetime Income Accelerator (LIA), if you annuitize prior to the 10th benefit anniversary, you cannot become eligible to receive the Lifetime Income Accelerator amount in the future. (Continued) ORD 04136 Ed. 3/18 p2 of 8

SECTION 4 PAYMENT DATA (continued) Annual Withdrawal Amount - (For contracts with Lifetime Five benefit and Guaranteed Minimum Withdrawal Benefit only; payable until the Protected Withdrawal Value reaches zero.) Joint and Survivor Life Annuity Payments for as long as you or the joint annuitant are living. At the death of the first to die, 100% of the income will continue to the survivor unless otherwise specified as follows: Choose only one: Continue % to the surviving annuitant or % to joint annuitant of the income. At the death of the surviving annuitant, nothing more will be payable, unless a certain period is specified. I would like to elect a certain period as follows: years If the death of the last to die of the annuitants were to occur before the end of this specified period, the remaining certain period payments will continue to the estate of the last to die, unless indicated otherwise in Section 5. Interest Payment Option (Not available for 403(b) or 401(a).) - Proceeds held at interest, with the right to withdraw any unpaid balance. The Interest Payment Option may not be available on all products. If this option is chosen, earnings will be fully taxable and reportable. Check one box: Hold interest to accumulate. Interest will be paid to you annually unless a different frequency is checked. Lump Sum at Maturity - This option is fully taxable and reportable to the Owner. Please fill out Section 9 for tax withholding election. SECTION 5 BENEFICIARY If not completed, payments will be made to the beneficiary designated under your deferred annuity. Primary class Name of beneficiary (first, middle initial, last name) If trust, include name of trust and trustee s name. Date of Birth Social Security Number Beneficiary s relationship to owner Check only one: Primary class Secondary class Name of beneficiary (first, middle initial, last name) If trust, include name of trust and trustee s name. Date of Birth Social Security Number Beneficiary s relationship to owner ORD 04136 Ed. 3/18 p3 of 8

SECTION 6 PAYMENT FREQUENCY Payment Frequency: Monthly Quarterly Semiannually Annually (Please note: if frequency is not selected default frequency will be monthly.) SECTION 7 GMIB FEATURE Exercise my GMIB feature. (You must be within your eligible window to exercise this benefit and payment frequency can only be monthly.) YES NO N/A If Yes, please choose the following annuity type. Single Life with Period Certain Joint Life with Period Certain The GMIB feature is not available with all contracts, please refer to your prospectus/contract to confirm if you have this feature available on your contract. SECTION 8 PROOF OF AGE AND GENDER Provide a copy of one of the following documents to confirm age and gender of Key Life/Annuitant. Driver s License or State ID Passport Birth Certificate Military ID ORD 04136 Ed. 3/18 p4 of 8

SECTION 9 INCOME TAX WITHHOLDING NOTICE AND ELECTION Tax Withholding Election. (This Section applies to withdrawals from life insurance contracts, endowment contracts, non-qualified annuities and IRAs, to withdrawals from a Section 403(b) tax-deferred annuities and Section 401(a) qualified plans that do not qualify as eligible rollover distributions). The taxable portion of the withdrawal that you receive will be subject to federal income tax withholding and state income tax withholding, where applicable, unless you elect not to have withholding apply. The taxable portion of your withdrawal will normally be subject to federal income tax withholding at a rate based on withholding tables for annuity payments. Your withdrawal may also be subject to state income tax withholding in certain states. If this Section is not returned or left blank, by signing and dating this form in Section 12, you have made the following election: I do not want federal or state income tax withheld. I understand that I may be subject to penalties if my income tax withholding and estimated tax payments are not sufficient to meet the applicable tax requirements. Non-Periodic Payments (Lump Sum): If you want to have federal or state income taxes withheld from the taxable portion of your distribution, please complete the following election information. 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. % or $ To have state income taxes withheld on the taxable portion of my distribution as indicated below: % or $ Periodic Payments Only (All other options): Withholding Allowances (applies to withdrawals from Immediate Annuity and Claim Settlement Certificates). Please complete the following information. This information will be used to compute the applicable income tax withholding on your withdrawal. Withhold federal income taxes on the taxable portion of my withdrawal based on the following criteria: Marital Status: Married Single Total allowances you are claiming: or Percentage: %* Specific dollar amount: $ If you want to have state income taxes withheld from the taxable portion of your withdrawal, please check the appropriate box(es) below and complete any other applicable boxes. Please be advised that if your resident state requires mandatory withholding, we will withhold the default amount your state requires if you elect no withholding. Withhold state income taxes on the taxable portion of my withdrawal based on the following criteria: Marital status: Married Single Exemptions Other (Please specify) or Percentage: %* Specific dollar amount: $ *Percentage/Dollar amount cannot be less than the minimum required by your state of residence. If the amount above is less, we will withhold the default amount required by your state. 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 04136 Ed. 3/18 p5 of 8

SECTION 10 PAYMENT AND MAILING INSTRUCTIONS Please attach a voided check/deposit slip The Payee(s) authorize PALAC to initiate credit entries, and if necessary, debit entries and adjustments for any credit entries made in error to the account indicated below and the Financial Institution named below to credit and/or debit the same to such account. 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 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. OR make check payable to: Owner (Address of Record or specify address below.) Special payee - (Please enter special payee s name and address below. Payment to a special payee will be fully taxable and reportable to the Owner. Signature Guarantee is required in section 12 for all Non New Jersey Special Payees.) 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 Country This authority is to remain in full force and effect until PALAC has written notification from me/us of the termination of this agreement in such time and in such manner as to afford PALAC and the Financial Institution reasonable opportunity to act upon change of Payee by the Owner. I understand that PALAC is relying on the information that I have provided and further understand that PALAC will not be liable for any losses or charges due to incorrect, outdated or incomplete information provided. ORD 04136 Ed. 3/18 p6 of 8

SECTION 11 OWNER S TAX CERTIFICATION (SUBSTITUTE W-9) If not a U.S. person (including resident alien) or U.S. Entity, submit the applicable Form W-8 (BEN, BEN-E, ECI, EXP or IMY). In most instances, Form W-8BEN will be the appropriate form. 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). SECTION 12 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. 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. 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: Acknowledge that a death benefit is not payable if annuity payments are being made at the time of the decedent s death. Agree to the request(s) made on this form; Understand that there may be tax implications as a result of the request(s), including requests to pay advisory fees, and that the request(s) (including tax reporting and withholding) cannot be reversed once processed. (We encourage you to consult your tax advisor prior to a withdrawal); Certify to the tax certification information completed above; Certify that I have a legal right to sign this form; and Understand that if I am married, and if this request applies to amounts held by a retirement plan described in sections 401(a), 403(a) or 403(b) of the IRS Code, then spousal consent and other requirements may apply. 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. (Continued) ORD 04136 Ed. 3/18 p7 of 8

SECTION 12 SIGNATURES (continued) PLACE SIGNATURE GUARANTEE STAMP IN THE BOX (IF APPLICABLE) I (we) authorize Prudential to initiate credit entries and if necessary, adjustments for any credit entries made in error to my (our) account as indicated above. I (we) also direct the bank named above to credit and/or debit the same to such account. This authorization will remain in effect until further written notice from me (us) is received and processed by the Prudential Annuities Service Center. I understand that Prudential is relying on the information that I (we) have provided on this form, and further understand that Prudential will not be liable for any losses or charges due to incorrect, outdated, or incomplete information that has been provided on this form. The Internal Revenue does not require your consent to any provision of this form other than the certifications required to avoid backup withholding. SIGN HERE Owner s signature (Title, if applicable) Date of signature (Month / Day / Year) SIGN HERE Joint Owner s signature (Title, if applicable) 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 04136 Ed. 3/18 p8 of 8