r e q u e s t f o r r e q u i r e d m i n i m u m d i s t r i b u t i o n ( R M D ) Annuities are issued by Pruco Life Insurance Company, in New York, by Pruco Life Insurance Company of New Jersey and The Prudential Insurance Company of America (PICA) (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 contractual obligations. The Rock Prudential Logo is a registered service mark of PICA and its affiliates. Use this form to request the minimum distribution payout from your Individual Retirement Annuity (IRA)/ Simplified Employee Pension (SEP) Plan. Please use a separate request form for each annuity contract. Not for use with Beneficiary Annuity contracts. Instructions All information must be typed or printed using blue or black ink. 1. OWNER INFORMATION Annuity Number Owner Name (First, Middle, Last Name) Owner Social Security/Tax I.D. Number Telephone Number 2. calculation elections Please choose one of the following options. If no form is returned, or if a form is returned with no calculation method specified, the default will be Option B and no amounts will be distributed from this contract. A. Please calculate my RMD using the uniform table. (Prudential will assume you have chosen this election in future years unless we are notified otherwise.) B. I have chosen to take my RMD payment from another company. (Proceed to the signature section 8. Prudential will assume you have chosen this election in future years unless we are notified otherwise.) C. Please calculate my RMD under the spousal exception to the RMD rules. I understand that in order to be eligible to have my RMDs calculated using the joint life expectancy of myself and my spouse, 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). Name of Spouse (First, Middle, Last Name) Spouse s Date of Birth Spouse s Social Security Number D. I have performed my own calculation: Please distribute. I understand that this distribution will be for one year only. E. The annuity referenced above is a 403(b) tax sheltered annuity 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 option in future years until we are otherwise notified.) Page 1 of 5
3. program details In certain instances you must provide us with a December 31 Account Value or an adjustment to your December 31 Account Value in order for us to perform your RMD calculation. A. If your Prudential annuity did not have an Account Value on December 31 of the year prior to your minimum distribution year, please provide the December 31 Account Value from your previous IRA, 403(b) or eligible retirement plan: Example: You establish your Prudential annuity on June 1 of this year. You must provide the December 31 of last year s Account Balance in order for Prudential to properly calculate your current RMD. B. If you transferred or rolled over funds to your Prudential annuity within 60 days after December 31 of the year prior to your minimum distribution year, and the funds were not included in the December 31 Account Value at your previous IRA, 403(b) or eligible retirement plan, please provide us with the amount of the transfer/rollover: Example: You request a rollover from your IRA held at your bank, which is distributed on December 26 of this year. The rollover is added to your Prudential annuity on January 3 of next year. Because this rollover amount was not included in the December 31 of this year s Account Value of your bank IRA and was not included in the December 31 of this year s Account Value of your Prudential annuity, we must add the rollover amount to your annuity Account Value in order to properly calculate your RMD for next year. 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: If you are establishing a new contract and you have reached age 70½, do not complete this section. 4. initial minimum distribution I authorize Prudential to draw my initial minimum distribution check as follows: (Choose only one.) At the end of the calendar year in which I reach age 70½; or On April 1 of the year after the calendar year in which I reach age 70½. Note: By electing an April 1 distribution, you will receive two minimum distribution 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. 5. payment details A. Please specify a date to begin your payment(s): Frequency of your payment: Monthly* Quarterly Semiannually Annually B. Please specify a date to begin future payment(s): Frequency of your payment: Monthly* Quarterly Semiannually Annually *Please refer to the Minimum Distribution Information Package for restrictions on monthly withdrawals. Withdrawals will be deducted from each fund in the proportion that it bears to the total Account Value (Pro-Rata), unless indicated below. Note: If you have a Highest Daily Guaranteed Return Option, 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, withdrawals must be deducted pro-rata. *Including any applicable elections with the Beneficiary Income Option or Lifetime Income Accelerator **Including any applicable elections with the Lifetime Income Accelerator Fund Percentage (%) Fund Percentage (%) Percentages must total 100%. % % % % Page 2 of 5
6. payment AND MAILING instructions A. Payment Instructions Direct Deposit (ACH) to a Bank 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 Name of depositor on bank records (first, middle initial, last name) Checking Savings Attach voided check here. Name on bank account Check no. 1234 Street address City, State ZIP DATE pay to the order of $ DOLLARS FOR 123456789 ABA number (9 digits) 55555555 55555 1234 Bank account number OR make check payable to: Owner (Address of Record or specify address below.) Special payee (Please enter special payee s name and address below.) Name of special payee if selected above Street City State ZIP Code Country Page 3 of 5
If this section is left blank then you are electing to not have Federal or State taxes withheld. However, you will still be liable for any applicable taxes. 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. 7. income tax withholding notice and election I elect: 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. 8. signatures By signing below, I (we) acknowledge the following: If my Account Value is reduced to zero as a result of withdrawals, the death benefit (not including HD7 with 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. 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. If I have not taken the required minimum withdrawal by the end of November each year, Prudential is authorized to send me the balance necessary to meet the minimum distribution requirement. Prudential s minimum distribution payout applies to this contract only. 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, 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 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. (continued) Page 4 of 5
8. signatures (continued) 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. If not a U.S. person 5(including resident alien), submit the applicable Form W-8(BEN, ECI, EXP or IMY). In most instances, Form W-8BEN will be the appropriate form. Sign Here Owner s Tax Certification (Substitute W-9) Under penalty of perjury, I certify that the taxpayer identification number (TIN) I have listed on this form is my correct TIN. I further certify that: I am a U.S. person (including resident alien). I am not a U.S. person (including resident alien). I am a citizen of I have been notified by the Internal Revenue Service that I am subject to backup withholding due to underreporting of interest or dividends. 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 and date Sign Here Party-In-Interest s signature (if any) and date Annuities Service Center 1-888-778-2888 8:00AM 7:00PM ET, Monday Thursday 8:00AM 6:00PM ET, Friday Fax: (800) 576-1217 www.prudential.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 Page 5 of 5