Request for Partial or Full Withdrawal from a Claim Settlement Certificate 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. Instructions: Use this form to request a partial or full withdrawal from your Claim Settlement Certificate. On these pages, I, you, your, and my refer to the certificate owner(s). We, us, and our refer to the Prudential company that issued the certificate. ABOUT PARTIAL OR FULL WITHDRAWAL A partial or full withdrawal from a Claim Settlement Certificate is permitted only if your certificate provides for a right of withdrawal. For certificates that are life contingent, where your payments will continue for your life even after the certain period ends, only the certain period may be withdrawn. IMPORTANT TAX INFORMATION We present this information based on our understanding of tax law. You may wish to consult with a tax or legal adviser because neither we nor our representatives can provide tax or legal advice. Federal and state income tax withholding. Federal and some state tax laws require us to withhold income taxes from certain cash payments unless you elect out of withholding and in certain other circumstances. We are required to withhold federal income taxes and certain state income taxes from the taxable portion of any withdrawal from a non-qualified annuity, an IRA, a Roth IRA, a Section 403(b) tax-deferred annuity, or a Section 401(a) qualified plan. If your withdrawal is from a Section 403(b) tax-deferred annuity or a Section 401(a) qualified plan, and is an eligible rollover distribution, you will not be able to elect out of federal income tax withholding. Federal taxes will be withheld at a 20 percent rate, unless you elect to have your eligible rollover distribution directly rolled over to an IRA or to another qualified plan. You will not be able to elect out of withholding if we are notified that your taxpayer identification number (TIN) is incorrect. Estimated tax and possible penalties. 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. You may be subject to Internal Revenue Service (IRS) penalties, including fines and imprisonment, if you fail to provide your correct TIN, fail to report taxable interest or dividends on your tax return, or give false tax information. You may also be subject to a 10 percent federal income tax penalty if you are under the age of 59½. Taxpayer identification number and U.S. citizenship. You must give your TIN in section 6 of this form. If the contract owner is an individual, this is usually the Social Security number. If you are not sure which number to put on the form, please refer to the chart below. You must state whether you are or are not a U.S. citizen. If you are not a U.S. citizen or resident alien, you must provide the country of which you are a citizen and submit the applicable IRS Form W-8(BEN, BEN-E, ECI, EXP, IMY). In most situations the IRS Form W-8BEN will be the appropriate IRS Form W-8. Please note that if you are a U.S. Citizen, 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. Page 1 of 6 (Do not return this page)
IMPORTANT TAX INFORMATION (continued) Use this table to determine the taxpayer identification number to include in section 6. For this type of certificate ownership: Individual Joint (two or more individuals, including husband and wife) Custodian account of a minor (UGMA/UTMA) Sole proprietorship Grantor Trust For this type of certificate ownership: Association, club, religious, charitable, educational, or other tax-exempt organization Partnership Valid trust, estate trust, or pension trust Give the Social Security number of: Individual Actual certificate owner. If combined funds, the first individual on the certificate. Minor Owner of business Grantor Give the employer identification number of: Organization Partnership Legal entity (Do not furnish the identification number of personal representative or trustee unless the legal entity itself is not designated in the policy.) Backup withholding. You must tell us if the IRS has notified you that you are subject to backup withholding because you did not report all your taxable interest and dividends on your tax return. You are not subject to backup withholding if you did not receive such a notice from the IRS, or if the IRS recently told you that you are no longer subject to a backup withholding order. If you have been notified that you are subject to backup withholding, please check the appropriate box in section 6. 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. Page 2 of 6 (Do not return this page)
Request for Partial or Full Withdrawal from a Claim Settlement Certificate Please print using blue or black ink. 1. ABOUT THE CERTIFICATE OWNER Certificate number Name of certificate owner (First, Middle, Last) Telephone Number Email Address Certificate owner s date of birth 2. WITHDRAWAL AMOUNT If you are applying for a full withdrawal of your certificate, all your rights, privileges, and benefits under the contract are cancelled: Proof of age is required prior to first distribution at age of majority (For example: Copy of your birth certificate or driver s license.) The Claim Settlement Certificate or, if under disability claim, the original policy must be submitted with this request. (Check one.) Partial withdrawal of $ Full withdrawal (mm/dd/yyyy) If we require additional information to complete this request, please indicate who Prudential should contact: Owner Financial Professional Page 3 of 6
3. FEDERAL AND STATE INCOME TAX WITHHOLDING ELECTION Tax Withholding Election. (This section does not need to be completed if the withdrawal is from an Interest Payment Option Certificate.) 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. Please be advised that if your resident state requires mandatory income tax withholding, we will withhold the default income tax amount your state requires if you elect not to have withholding apply. 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. If this page is not returned or you do not make a valid withholding election, Prudential will be required to withhold federal and state taxes in accordance with law. 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. Federal Income Tax Election Withhold 10% Federal income taxes. Withhold greater than 10% Federal income taxes % or $ (Minimum 10%) State Income Tax Election Withhold state income taxes % or $ 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% Page 4 of 6
4. PAYMENT AND MAILING INSTRUCTIONS (PLEASE COMPLETE ONLY PART A OR B.) A. Payment to an individual. (Payment will be made via a check sent first class U.S. mail.) Make check payable to: Owner 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 6 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 certificate owner and mailed to the Address of Record. Name of special payee if selected above Mail check to: Owner at address of record Name and address listed below Name (First, Middle, Last) Street Address City State Zip Country B. Payment to a bank. (Payments will be made to your bank via Electronic Funds Transfer.) Please allow 1-3 business days from the processing date to receive the funds in your bank account. 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 of joint depositor on bank records (First, Middle initial, Last) 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. Page 5 of 6
5. LOST CERTIFICATE DECLARATIONS Complete this section only if the certificate is not being submitted. By signing below, I certify that: The certificate has been lost or destroyed and is not in the possession of anyone; The certificate has not been assigned, transferred, or pledged as security to anyone. (If the certificate is assigned, the assignee must sign below). SIGN HERE Owner Signature Date of Signature (mm/dd/yyyy) SIGN HERE Primary Beneficiary s Signature Date of Signature (mm/dd/yyyy) 6. SIGNATURE(S) By signing below, I agree to the request(s) made on this form. Signature Guarantee: Required for all signing certificate owners who have reached the age of majority. The Signature Guarantee Stamp, if applicable, can be obtained at a local financial institution and placed in the box. Not Required if certificate was issued in or if the owner resides in the state of New Jersey. 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. Certificate Owners Printed Name SIGN HERE Certificate Owner s Signature Date of Signature (mm/dd/yyyy) 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 Page 6 of 6 Overnight Service, Certified or Registered Mail Delivery Prudential Annuities Service Center 2101 Welsh Road Dresher, PA 19025