Systematic Withdrawal Enrollment Form

Annuities are issued by Pruco Life Insurance Company, in New York, by Pruco Life Insurance Company of New Jersey (these
entities are referred to as “Prudential” below). Both 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 The Prudential
Insurance Company of America (PICA) and its affiliates.
This form is for use with new and existing Prudential Premier, Premier Retirement and Premier Advisor Variable Annuities. For
new Annuities, also check the applicable box in the Optional Administrative Program section of the Annuity Application. There
is a $100 minimum on Systematic Withdrawals. Funds that are part of a Systematic Withdrawal Program cannot be included in
an automatic rebalancing program. This form is not to be used for a 72(t) or 72(q) request (substantially equal periodic payment
program) or Required Minimum Distributions. For 403(b) or ORP withdrawals, the 403(b) Tax Sheltered Annuity or ORP form
must be used.
Instructions: All information must be typed or printed using blue or black ink.

SECTION 1 OWNER INFORMATION

Annuity Number

Owner Name (First, Middle, Last Name)

Joint Owner Name (If applicable)

Owner Social Security/Tax I.D. Number Telephone Number

SECTION 2 systematic withdrawals

For a new Annuity, if no date is provided or the date is in the past, the first withdrawal will be processed 30 days from the Annuity
issue date.
If paperwork is received after the start date listed, then it will begin 30 days from the date given.
Payments to begin: Withdrawals will begin on date specified in accordance with frequency elected below.

Start Date / / (Month / Day / Year)

I hereby request that systematic withdrawals be made from my account according to the following terms.
Frequency: Systematic Withdrawals are processed and valued as of the date they are scheduled, unless the scheduled day
is not a Valuation Day (when the NYSE is open for trading). In that case, withdrawals will be processed and valued on the next
Valuation Day.
Frequency: Monthly Quarterly Semiannually Annually

Withdrawal Amount (Select one): Dollar amount withdrawals from a Fixed Option cannot exceed the growth of the option.
Withdraw $
Earnings only from
(This election may not be available for all products, see your prospectus for details.)

(Continued)
ORD 03701 Ed. 1/11 p1 of 6
SECTION 2 withdrawal information (continued)

For Contracts with the Lifetime Five (LT5), Spousal Lifetime Five (Spousal LT5), Highest Daily Lifetime Five (HD5),
Highest Daily Lifetime Seven (HD7), Highest Daily Lifetime Seven with Beneficiary Income Option (HD7 with BIO),
Highest Daily Lifetime Seven with Lifetime Income Accelerator (HD7 with LIA), Spousal Highest Daily Lifetime Seven
(Spousal HD7), Spousal Highest Daily Lifetime Seven with Beneficiary Income Option (Spousal HD7 with BIO), Highest
Daily Lifetime 7 Plus (HD7 Plus), Highest Daily Lifetime 7 Plus with Beneficiary Income Option (HD7 Plus with BIO),
Highest Daily Lifetime 7 Plus with Lifetime Income Accelerator (HD7 Plus with LIA), Spousal Highest Daily Lifetime 7
Plus (Spousal HD7 Plus), Spousal Highest Daily Lifetime 7 Plus with Beneficiary Income Option (Spousal HD7 Plus with
BIO), Highest Daily Lifetime 6 Plus (HD6 Plus), Highest Daily Lifetime 6 Plus with Lifetime Income Accelerator (HD6 Plus
with LIA), Spousal Highest Daily Lifetime 6 Plus (Spousal HD6 Plus), Highest Daily Lifetime Income (HDI), Highest Daily
Lifetime Income with Lifetime Income Accelerator (HDI with LIA) or Spousal Highest Daily Lifetime Income (Spousal HDI)
Optional Living Benefits: Please refer to the prospectus for further details and availability on the living benefits we currently offer
for your annuity product.
 ithdrawals based on the Annual Income Amount – Your withdrawal amount will be calculated based on the LT5 benefit
W
suite, HD5, HD7 benefit suite, HD7 Plus benefit suite, HD6 Plus benefit suite or HDI benefit suite, Annual Income Amount.

Withdrawals based on the Annual Withdrawal Amount (Only available with LT5 benefit suite) – Your withdrawal amount will
be calculated based on the LT5 Annual Withdrawal Amount, initially equal to 7% of the initial Protected Withdrawal Value.
The Protected Withdrawal Value is determined as of the date you make your first withdrawal under the Annuity following your
election of the LT5 benefit suite, HD5 or the HD7 benefit suite.
For the HD7 Plus benefit suite, the HD6 Plus benefit suite or HDI benefit suite the Protected Withdrawal Value is determined at
the time of first Lifetime Withdrawal under the Annuity. All systematic withdrawals are considered Lifetime Withdrawals for these
annuities.
You must instruct us to change your Systematic Withdrawal amount if a post-withdrawal step up occurs under any of the above
living benefits. Your Systematic Withdrawal will not automatically be updated.

IMPORTANT: If you request an unscheduled partial withdrawal from this contract (in addition to this Systematic
Withdrawal Program) you may exceed the Annual Income Amount (resulting in an excess withdrawal) or Annual
Withdrawal Amount permitted under the benefit you have elected.

An “excess withdrawal” refers to a withdrawal that (i) is not taken to satisfy a required minimum distribtion requirements for
this annuity as calculated by us and distributed under a program that we administer and (ii) exceeds your Annual Income
Amount (or your Annual Withdrawal Amount, for LT5). If you take an excess withdrawal, it proportionally reduces your Annual
Income Amount (or Annual Withdrawal Amount, for LT5) in future years. Each systematic withdrawal you take that is an excess
withdrawal will proportionally reduce your Annual Income Amount (or Annual Withdrawal Amount, for LT5). Thus, you need
to be aware of how your systematic withdrawal amount compares to your current Annual Income Amount (or current Annual
Withdrawal Amount, for LT5).
Reductions are based on the actual “gross” amount of the withdrawal, including any Contingent Deferred Sales Charge (CDSC)
and a Market Value Adjustment (“MVA”) (positive or negative) that may apply. Thus, you should be aware that if you ask to
receive a specified withdrawal amount that itself is not deemed an Excess Income, with the understanding that any charges (or
MVA) applicable to that withdrawal will be assessed against your remaining Unadjusted Account Value, then any amount of the
withdrawal exceeding the Annual Income Amount would result in that portion of the withdrawal being treated as Excess Income.
If you participate in this 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 Annual Income Amount under this benefit. If your withdrawal does not exceed the
Annual Income Amount, it will not be subject to a CDSC - - even if the withdrawal exceeds the free withdrawal amount. 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 Annual Income Amount. In that scenario, the withdrawal would be deemed Excess Income – thereby reducing your Annual
Income Amount for future years. Prudential will not prevent additional withdrawals from being taken. You are responsible for
ensuring you do not exceed the Annual Income Amount (or Annual Withdrawal Amount for LT5) under any of the above living
benefits.
There is a 3 year waiting period (from the date HD7 with Lifetime Income Accelerator, HD7 Plus with Lifetime Income Accelerator
HD6 Plus with Lifetime Income Accelerator or HDI with Lifetime Income Accelerator is elected) before you can become eligible to
withdraw the Lifetime Income Accelerator amount.

(Continued)

ORD 03701 Ed. 1/11 p2 of 6

SECTION 2 withdrawal information (continued)
Withdrawals under the HD6 Plus benefit suite or HDI benefit suite are subject to all of the terms and conditions of the Annuity,
including any applicable CDSC for the Non-Lifetime Withdrawal as well as withdrawals that exceed the Annual Income Amount.
Withdrawals made while the HD6 Plus benefit suite or HDI benefit suite is in effect will be treated, for tax purposes, in the same
way as any other withdrawals under the Annuity. Any withdrawals made under the benefit will be taken pro rata from the Sub-
accounts (including the AST Investment Grade Bond Sub-account) and the DCA MVA Options, including any 6 or 12 month
DCA Program you may be participating in. If you have an active Systematic Withdrawal program running at the time you elect
this benefit, the program must withdraw funds pro-rata. The first Systematic Withdrawal that processes after your election of the
benefit will be deemed a Lifetime Withdrawal. Withdrawals from the MVA Options may be subject to an MVA.
You can make withdrawals from your Annuity without purchasing the HD6 Plus benefit suite or HDI benefit suite. The HD6 Plus
benefit suite or HDI benefit suite provides a guarantee that if your Account Value declines due to Sub-account performance, you
will be able to receive your Annual Income Amount in the form of periodic benefit payments.
Withdrawals from an MVA Option more than 30 days prior to the end of the Guarantee Period will be subject to a “Market Value
Adjustment”, which can either increase or decrease your Account Value. Premature withdrawals from any 6 or 12 Month DCA
MVA Program you may be participating in may also be subject to a Market Value Adjustment. Please see the prospectus for
further details.
For Dollar Withdrawal Amounts: Funds will be withdrawn pro-rata from Variable Investment Options from each Sub-account
in proportion to the total value of the Sub-account, unless instructed differently below. Please check your most recent statement
for the available Sub-accounts. If you have the Highest Daily Guaranteed Return Option (HD GRO) Benefit, Highest Daily
Guaranteed Return Option II (HD GRO II), Guaranteed Return Option Plus II (GRO Plus II), HD5, HD7 benefit suite, HD7 Plus
benefit suite, HD6 Plus benefit suite or HDI benefit suite, your withdrawal must be deducted pro-rata.
Percentages must total 100%.

% from % from

% from % from

% from % from
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 charges and/or federal
and state taxes will be deducted from the contract value.)
Gross amount (Check will be for the amount indicated above, less any applicable contingent deferred sales charges and/or
federal and state taxes.)
SECTION 3 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 4 income tax withholding notice and election

If this section is left blank, or if this page is not returned, or you do not make a valid election to not have federal and/or state
tax withheld, Prudential is required to withhold Federal and/or State taxes.
I elect:
To have 10% Federal income taxes withheld on the taxable portion of my distribution.
Not to have Federal or State income taxes withheld.
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 $
(Continued)

ORD 03701 Ed. 1/11 p3 of 6

SECTION 4 income tax withholding notice and election (continued)

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.
For 401(a) The eligible rollover portion of your distribution is subject to a mandatory 20% federal income tax withholding unless directly
rolled to a traditional IRA, Roth IRA, a 457 (governmental), or another plan qualified under Internal Revenue Code section 401(a).

SECTION 5 payment AND MAILING 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  Checking  S

 avings

Name of depositor on bank records (first, middle initial, last name)

Attach Voided Check Here

Name on bank account Check no. 1234

Street address
City, State ZIP

VOID
Date_________________
Pay
to the
order of $

DOLLARS

FOR

123456789 55555555 55555 1234

ABA number (9 digits) 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.)

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

ORD 03701 Ed. 1/11 p4 of 6

SECTION 6 signatures

For a Partial Exchange of Assets: Internal Revenue Procedure 2008-24 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 2008-24 provides that a partial direct transfer as described above will be treated as a tax-free §1035
exchange if either:
1. No distributions are made from either of the two contracts for 12 months following the date of the transfer; or
2. If there is a distribution during the 12-month period, the individual receiving the distribution can show that one of the following
conditions occurred between the date of the transfer and the date of the distribution:
 The individual attained age 59½.
 The individual died.
 The individual became disabled (as defined under section 72(m)(7)).
 The distribution is allocable to investment in the contract before August 14, 1982.
 The individual finalized a divorce or suffered from loss of employment.
Please check the box of the above condition that occurred between the date of the transfer and the date of the
distribution being requested. If no exception applies this distribution will disqualify any and all Partial Exchange of
Assets.

Partial direct transfers that do not meet the requirements above are treated as a taxable distribution (under section 72(e)),
followed by a payment for the second contract.

TRANSACTION CONFIRMATIONS
We may confirm regularly scheduled transactions, including, but not limited to, the Annual Maintenance Fee, electronic fund
transfer, Systematic Withdrawal/ Minimum Distribution / 72(t) / 72(q) programs, static rebalancing, and Dollar Cost Averaging in
quarterly statements instead of confirming those transactions immediately.

Any withdrawal in the form of a check will be made payable to all Owners or a Financial Institution FBO the Owner. If the account
name is not identical to that of the Owner(s), this form must be notarized.
If a Systematic Withdrawal Program is elected that requests the withdrawal from a specific Sub-account, and the Account Value
in that Sub-account is zero due to a transfer, the Systematic Withdrawal Program will terminate. New written instructions will be
required to restart a Program.
This section applies to withdrawals from a non-qualified annuity, an IRA, a Roth IRA, or a Section 401(a) qualified plan. 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 any withdrawal will normally
be subject to Federal income tax withholding at a rate of 10% for non-annuity payments, and is based on withholding tables for
annuity payments.
Your withdrawal may also be subject to State income tax withholding in certain states. The percent or dollar amount cannot be
less than the minimum required by your State of residence. If the amount you select is less, we will withhold the required default
amount. If your resident State requires mandatory withholding, we will withhold the default amount your State requires even if
you elect no withholding.
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.
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.
If you purchased Non-Qualified Annuity Contracts from Pruco Life 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.

(Continued)

ORD 03701 Ed. 1/11 p5 of 6

SECTION 6 signatures (continued)

By signing below, I (we):

Acknowledge that if my Account Value is reduced to zero as a result of withdrawals, any 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.
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 5 (the “Financial Institution”). I/we understand receipt of funds may take up to 2
business days.
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: 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 (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.

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.

SIGN HERE µ / /
Contract owner’s signature Month Day Year

SIGN HERE µ / /
Joint owner’s signature (if applicable) Month Day Year

SIGN HERE µ / /
Party-In-Interest’s signature (if any) Month Day Year

Annuities Service Center Regular Mail Delivery Overnight Service, Certified or

Investor Line: 1-888-778-2888 Annuities Service Center Registered Mail Delivery
Financial Professionals: 1-800-513-0805 P.O. Box 7960 Prudential Annuities Service Center
8:00AM–7:00PM ET, Monday–Thursday Philadelphia, PA 19176 2101 Welsh Road
8:00AM–6:00PM ET, Friday Dresher, PA 19025
Fax: (800) 576-1217
www.prudentialannuities.com

ORD 03701 Ed. 1/11 p6 of 6