prudential smartsolution ira application and brokerage agreement

Prudential SmartSolution IRA Application and Brokerage AgreementThrough this application and brokerage agreement (“The Agreement”) you are creating a custodial Individual Retirement Account (IRA) with Prudential Bank & Trust, FSB (PB&T) as custodian and a brokerage account with Prudential Investment Management Services LLC (PIMS).

Choose type of IRA:

Traditional IRA Roth IRA Beneficiary IRA Decedent’s Name ______________________________ Social Security Number ________________________

1 P e r s o n a l i n f o r m a t i o nFirst Name ______________________________ Middle Initial ______ Last Name

Home/Legal Address (if different than Mailing Address) __________________________________________________________________

City_______________________________________________ State ______________________ ZIP Code __________________

Mailing Address ____________________________________________________________________________________________


Home Phone __________________________ Business Phone ______________________ Cell Phone _________________________

Email Address _______________________________________________ Social Security Number ____________________________

Country of Citizenship _________________________________ Date of Birth ___________________ Gender: Male ____ Female _____

Are you a Nonresident Alien? Yes No (If yes, W-8 Form is required.)

Marital Status: Single Married Widowed/Divorced

Number of Dependents ______ (If none, enter 0)

Residence Status: Rent Own If you own your residence, do you have a reverse mortgage? Yes No

Highest Education Level Attended (check one): High School College Graduate Studies None

T R U S T E D C O N TA C T *

Name __________________________________________________ Relationship _______________________________________

Home Address ______________________________________________________________________________________________


Home Phone ________________________ Business Phone _______________________ Cell Phone ___________________________

*Only to be contacted in the event of suspected financial exploitation of a senior/vulnerable person.

For Prudential use only: 706

ROFM043_0003SSIRA_IFX_TGT_PS

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Prudential SmartSolution IRA Agreement

A D D I T I O N A L I N F O R M AT I O N

Employed by _______________________________________________________ Occupation ______________________________

Business Street Address _____________________________________________________________________________________


Do you have an existing account with Prudential Investment Management Services (PIMS)? Yes _ __ No _ __

If you have multiple accounts that should be linked for qualification of reduced sales charges on front-end-loaded mutual funds (please refer to the fund’s prospectus for this qualification), you should notify the firm where you hold the additional accounts. Investors may not realize the full breakpoint opportunity available if other firms are not notified.

Are you affiliated with or employed by FINRA or a member firm of a stock exchange or FINRA; are you a senior officer of a bank, S&L, insurance company, registered investment company or registered investment advisory firm; or are you in the securities department of any of the above or an immediate family member of any such person?

Yes __No ____If yes, list company name ________________________________________ Position _______________________

Are you a director, a 10% shareholder, or a policy-making executive officer of a publicly traded company?

Yes __No ____If yes, list company name ____________________________________________________________________

2 C l i e n t p r o fi l e i n f o r m a t i o nThis portion of the Agreement must be fully completed. Industry regulation requires us to obtain certain information to verify identification and to determine suitability of this account. Incomplete information will prevent this Agreement from being considered in good order and will delay opening your account. Prudential Financial cannot be held responsible for any delays in opening your account if information on this Agreement is incomplete.

I N C O M E A N D N E T W O R T H

Owner’s Tax Bracket: _______% (Approximate federal income tax bracket, based on previous year’s tax return.)

Check one box in each column. See definitions below if you have any questions.

Ranges Owner’s Annual Income (all sources)

Household Income Net Worth (assets minus liabilities)

Liquid Net Worth (exclude non-liquid assets)

$0–49,999

$50,000–99,999

$100,000–249,999

$250,000–499,999

$500,000–999,999

$1,000,000–4,999,999

$5,000,000+

D E F I N I T I O N SOwner’s Annual Income (all sources): Annual gross income, before any deductions for income taxes or qualified plan contributions, etc.

Household Income: Household gross income (all wage earners), before any deductions for income taxes or qualified plan contributions, etc.

Net Worth (assets minus liabilities): Your assets minus liabilities (include all investments and all liabilities). In other words, the value of everything you own less everything you owe.

Liquid Net Worth: Your assets that can be converted easily to cash without incurring a penalty or loss of principal. This includes cash, savings accounts or cash equivalents such as the cash value of a life insurance policy.

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R E A S O N F O R R O L L O V E R ( C H E C K A L L T H AT A P P LY )

Limited in-plan investment options Consolidation

Limited in-plan distribution options Financial/estate planning

Seeking additional features not currently offered in retirement plan Other __________________________________________

Restrictive in-plan deferral options (e.g. status/age)

I N V E S T M E N T O B J E C T I V E SPlease identify your investment objectives as they relate to the assets in your Prudential SmartSolution IRA by checking the appropriate boxes.

Primary Objective (required) Secondary Objective (not required)

Preservation of Capital

Income

Capital Appreciation

I N V E S T M E N T E X P E R I E N C EPlease indicate your years of experience with the following investment types (if no experience, please enter 0).

__________ Equities __________ Futures

__________ Bonds __________ Variable Contracts

__________ Mutual Funds __________ Limited Partnerships

__________ Options __________ Other ____________________________________________

L I Q U I D I T Y N E E D S Short-term (less than six months) Medium-term (six months to two years) Long-term (more than two years)

I N V E S T M E N T A P P R O A C HPlease select ONE description that best represents your investment approach to this account.

Conservative Prefer little risk and low volatility in return for accepting lower potential returns. Minimizing exposure of principal to loss or fluctuation is very important.

Moderate Willing to assume an average amount of market risk and volatility or loss of principal to achieve higher returns.

Aggressive Willing to sustain volatility or loss of principal and assume a high level of risk in pursuing higher returns.

Y E A R S T O R E T I R E M E N TPlease indicate the number of years until you will begin taking distributions from this retirement account.

0–5 years 6–10 years 11–15 years 16+ years

R E A S O N F O R VA R I A B L E A N N U I T Y W I T H P R U D E N T I A L I N C O M E F L E X B E N E F I T P U R C H A S E( I F A P P L I C A B L E )

Retirement Income Spousal Benefit Asset Accumulation

S O U R C E O F F U N D S F O R T H I S A C C O U N TPlease indicate the source of funds for this Prudential SmartSolution IRA below.

Plan maintained by Prudential Financial including 401(k), 401(a), 403(b), 457, Group IRA or other plans.

If either of the two following options are selected, an Investment Switch Form must be completed, signed and returned with this Agreement.

Plan maintained by an external service provider (NOT Prudential).

IRA.

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O T H E R I N V E S T M E N T S ( A P P R O X I M AT E )

After-Tax Brokerage and Mutual Fund Accounts $___________.00

After-Tax Bank Accounts $___________.00

Other Tax-Deferred Accounts $___________.00

Investment Real Estate (other than primary residence) $___________.00

Other Accounts $___________.00

3 I n v e s t m e n t i n s t r u c t i o n sPlease select EITHER Option 1 OR Option 2 (located on the next page).

O P T I O N 1 : G O A L M A K E R - ( N O T A V A I L A B L E I N N E W Y O R K )

GoalMaker®, an easy IRA asset allocation program, provides you with the ability to diversify your portfolio by investing among funds in different asset classes, based on your Investor Style and Years to Retirement. Please be aware of the following items related to GoalMaker:

• GoalMaker includes an Automatic Rebalancing feature. Near the end of each calendar quarter, your investment portfolio will be ‘rebalanced’ to your original specified target portfolio through a series of transactions.

• The portfolios are made up of a series of investments offered within the Prudential SmartSolution IRA, including mutual funds and other investments.

• Although it is an accepted investment strategy, there is no guarantee that Automatic Rebalancing will provide better performance in every circumstance.

• GoalMaker includes an optional Age Migration feature that automatically adjusts your allocations over time, based on the number of years you have left until retirement.

• You have the ability to enroll in or opt out of GoalMaker at any time, though changes in your GoalMaker status may not always take effect the same day your request is submitted.

If you would like to participate in the GoalMaker asset allocation program with Automatic Rebalancing and Age Migration, please select your portfolio by checking ONE portfolio code below.

G O A L M A K E R P O R T F O L I O S E L E C T I O N

YEARS TO RETIREMENT

INVESTOR STYLE

CONSERVATIVE MODERATE AGGRESSIVE

0–5 YEARS CO1 M01 R01

6–10 YEARS C02 M02 R02

11–15 YEARS C03 M03 R03

16 + YEARS C04 M04 R04

These model asset allocation portfolios are based on generally accepted investment theories that take into account the historic returns of different asset classes (e.g., equities, bonds or cash) over defined periods of time.

To the extent that this model asset allocation identifies any specific investment alternative available under the SmartSolution IRA, please note that other investment alternatives that have similar risk and return characteristics may be available. See the Prudential SmartSolution IRA Investment Selection Appendix A for more information.

In applying these asset allocation models to your individual situation, you should consider other assets, income and investments (e.g., equity in a home, other IRA investments, savings accounts, and interests in qualified or non-qualified plans) in addition to your interest in the SmartSolution IRA You may use your answers on the previous page as a guide to selecting your portfolio, however, you are free to select any portfolio, regardless of your actual Investor Style and Years to Retirement or Investment Approach.

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3 I n v e s t m e n t i n s t r u c t i o n s ( c o n t i n u e d )

O P T I O N 2 : C H O O S E Y O U R O W N I N V E S T M E N T S

• Please refer to the enclosed Prudential SmartSolution IRA Investment Selection Appendix A to choose your investments.

• Investment allocations MUST total 100%.

• Return your completed Appendix A with your completed application.

• Note: Incomplete information will prevent this application from being considered in good order, and the opening of your account will be delayed. Prudential Financial cannot be held responsible for any delays in opening your account if information on either this application or Appendix A is incomplete.

4 B e n e fi c i a r y d e s i g n a t i o n

The beneficiary designations will apply to the underlying custodial account investments and insurance products.

Please select a Primary Beneficiary(ies). Percentages must equal 100% (enter whole percentages only; no fractional amounts). You may also select a Contingent Beneficiary(ies). These percentages must also equal 100% (enter whole percentages only; no fractional amounts). Attach additional sheets if necessary.

NAME/ADDRESS/PHONE NUMBER BIRTH DATE SSN RELATIONSHIP WHOLE % ONLY TYPE

Primary

Primary Contingent

Primary Contingent

Primary Contingent

Primary Contingent

Primary Contingent

The benefits payable hereunder shall be paid in equal shares (or the whole percentages indicated above) to the Primary Beneficiary who survives the Account Holder. If no Primary Beneficiary survives, the payment shall be made in equal shares (or the whole percentages indicated above) to the Contingent Beneficiary who survives the Account Holder. If percentages shown above for surviving beneficiaries do not total 100%, benefits will be prorated in proportion to percentages shown.

This Beneficiary Designation is subject to all terms and provisions of the IRA. This Beneficiary Designation shall be effective only if accepted by the custodian prior to the death of the Account Holder. The Account Holder understands that if he/she is over age 70½, changing the beneficiary designation to a beneficiary with a shorter life expectancy may affect the minimum required distributions from the IRA. The Account Holder reserves the right to change the above beneficiary by filing a new Beneficiary Designation with the custodian, subject to acceptance by the custodian prior to the death of the Account Holder. If no beneficiaries are selected, benefits will be payable to the estate of the Account Holder.

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5 A c k n o w l e d g e m e n t s a n d a u t h o r i z a t i o n sPrudential SmartSolution IRA I understand that this IRA will be traded in an omnibus environment for the investments offered in the IRA, rather than on an individual account basis.

I understand that this IRA will be charged an Annual Custodial Fee, as specified below and described in the Custodial Agreement and Disclosure Notice.

Annual Custodial Fee: $40.00

The Annual Custodial fee is paid quarterly in arrears and covers services rendered during the applicable calendar quarter.

The Annual Custodial Fee, if applicable, will be deducted proportionally from each investment, except that which is invested in the variable annuity contract with the Prudential IncomeFlex benefit.

I understand that Prudential may change the Annual Custodial Fee from time-to-time and I agree to be bound by such changed fee.

I understand that a Prudential SmartSolution IRA offers such available features as the GoalMaker asset allocation tool with Automatic Rebalancing and Age Migration and PruSecure, an investment in a fixed rate group annuity. I realize that, if I am not interested in using these features, I may be able to buy the mutual funds offered through the Prudential SmartSolution IRA outside Prudential SmartSolution at a lower cost.

I understand that, unless stated otherwise, Prudential SmartSolution IRA investments are not insured by the FDIC, are not deposits or other obligations of any bank and are subject to investment risk including possible loss of principal invested.

I understand that some of the investments—both mutual funds and interests in group annuities—available as investments in the Prudential SmartSolution IRA are offered by Prudential affiliates, and the list of investments is subject to change.

I understand that Prudential Investments LLC is a Prudential subsidiary, and Prudential earns fees for managing these accounts.

Prudential Retirement Security Annuity III & IV and the Prudential IncomeFlex Benefit I understand that the Prudential IncomeFlex benefit is a feature of a variable annuity contract issued by Prudential Retirement Insurance and Annuity Company. I agree to be bound by the terms and conditions of the variable annuity as set forth in the annuity contract or certificate that I receive once my initial annuity purchase payment is accepted.

I understand that by selecting underlying investment options with the Prudential IncomeFlex benefit, I am investing in a variable annuity. I understand the fees for variable annuities will differ and may be higher than fees charged in my retirement plan or by other available investments. I also understand there is a $20,000 minimum initial purchase payment required to purchase a variable annuity with the Prudential IncomeFlex benefit. To meet this minimum initial purchase payment, in addition to my rollover from a qualified plan, I may be able to consolidate other outside qualified money.

I understand that, with respect to the Prudential Retirement Security Annuity III, subsequent purchase payments are not permitted (i.e. purchase payments made after the initial purchase payment). For Prudential Security Annuity III and IV, please consult the prospectus for details concerning the Prudential IncomeFlex benefit. With respect to the Prudential Retirement Security Annuity III, the prospectus among other things details the conditions under which the IncomeFlex benefit under your employment-based retirement plan is rolled over to the IncomeFlex benefit under the Prudential Retirement Security Annuity III.

PruSecure I understand PruSecure is an interest in a fixed-rate group annuity and—if I am not interested in using this feature—that alternative investments may be available from Prudential at a lower cost.

I have read and understand the PruSecure Disclosure Notice, and I agree to be bound by the terms of that notice. I understand PruSecure may include the imposition of a contingent deferred sales charge on amounts withdrawn from my account up to one (1) year from the initial deposit into PruSecure, and that amounts withdrawn from PruSecure may be subject to a market value adjustment. Both the contingent deferred sales charge and the market value adjustment are described in the PruSecure Disclosure Notice.

I understand PruSecure is an interest in a group annuity contract offered by The Prudential Insurance Company of America (the “Contract”), and I agree to be bound by the terms and conditions as set forth in the Contract and described in the certificate I will receive upon satisfactorily meeting the conditions to select PruSecure.

I understand that my Agreement to select PruSecure is not considered complete until Prudential determines that my Agreement has been received and adequate instructions have been received by Prudential. Issuance of a certificate to me shall constitute evidence of Prudential’s acceptance of my Agreement. The information set forth in this Agreement is, to the best of my knowledge, correct.

I understand that deposits into PruSecure are not FDIC insured, and that all deposits are only guaranteed by the Prudential Insurance Company of America.

I make this request to purchase PruSecure after having read and considered the Fraud Disclosure and other information provided in this form.

Miscellaneous I acknowledge that I have full authority and legal capacity to enter into this Agreement and that I have obtained and will provide you with all necessary authorizations from third parties to open accounts and effect securities transactions under this Agreement. I have the authority to purchase, hold or sell all securities purchased, held or sold by me through Prudential. I understand and agree that, for our mutual protection, you may record any of our telephone conversations without further notice. I also understand that all transactions shall be subject to the rules, regulations, customs and usages of the exchange, market or clearinghouse where executed, and to all applicable federal and state laws and regulations.

Under penalties of perjury, I certify that I am an individual, a U.S. citizen or other U.S. person (as defined in Form W-9), and that the information contained in the above Agreement (including my Social Security number) is accurate and complete. (NOTE: Failure to provide the correct Social Security number will subject my account to tax withholding.)

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By signing below, I confirm that I have received and reviewed the:

• IRA Customer Agreement and Disclosures document containing important product and regulatory information

• Prudential Retirement Security Annuity III and IV prospectus (if applicable)

This election and consent applies only to the documents needed to complete this IRA opening transaction.

I direct that my contribution be invested as indicated in Section 3 of this Agreement. I hereby irrevocably elect to treat this contribution as a rollover contribution.

I further acknowledge that information about each mutual fund is in the fund prospectus, which is available to me by calling 877-778-2100 or by visiting either prudential.com/prs or the mutual fund company’s website directly. I understand that I will receive from Prudential a current prospectus for each fund in which I am investing, and I agree to be bound by its terms.

I understand and agree that all transaction requests placed for my account are my responsibility and are placed at my own risk. I understand that I am approving any instruction (whether by telephone, in writing, through the internet or through other means) given to Prudential on my account, and I agree that Prudential Investment Management Services LLC and Prudential Insurance Company of America and their affiliates and subsidiaries will not be liable for any loss, cost or expense when they act upon such instructions reasonably believed by Prudential to be genuine.

I understand that Prudential may contact the Trusted Contact if there are questions or concerns about my whereabouts, how to contact me, my health status, that I might no longer be able to handle my financial affairs, or that I may be a victim of fraud or exploitation. I understand that Prudential might also contact the Trusted Contact to inquire about the identity of any legal guardian, executor, trustee, or holder of a power of attorney, or as otherwise permitted.

I agree and authorize Prudential and its affiliates to share my nonpublic personal information held by Prudential, including but not limited to my financial information, balances, or other financial transactions, to the Trusted Contact identified.

I represent that the Trusted Contact is at least 18 years of age.

I understand that, by naming a Trusted Contact, I am not naming that person as a beneficiary to my account. If I choose to name the Trusted Contact or any other person as a beneficiary, I must complete a separate beneficiary election.

I understand that naming a Trusted Contact is not required, that there is no requirement that Prudential reach out to the Trusted Contact and that I may withdraw this authorization at any time by notifying Prudential in writing to Prudential, PO Box 5310, Scranton, PA 18505 or by calling 877-778-2100. I and my heirs hold Prudential harmless if Prudential either acts, or fails to act, based upon the instructions in this form or in the exercise of Prudential’s best judgment.

To help the U.S. government fight the funding of terrorism and money-laundering activities, federal law requires that Prudential Retirement obtain, verify and record information that identifies each person who opens an account. What does this mean for you? When you open an account, we will ask for your name, address, date of birth and other information that will allow us to verify your identity.

I hereby adopt this Agreement and the Prudential Individual Retirement Account Customer Agreement, which I have received and read. I also acknowledge having received and read the Disclosure Notice and Brokerage Agreement. I understand that by adopting this Agreement I am establishing a custodial IRA with PB&T as custodian and a brokerage account with PIMS.

I understand this Agreement contains a pre-dispute arbitration clause. By signing below I agree to be bound by these provisions:

1. All parties to this Agreement are giving up the right to sue each other in court, including the right to a trial by jury, except by the rules of the arbitration forum in which a claim is filed.

2. Arbitration awards are generally final and binding; a party’s ability to have a court reverse or modify an arbitration award is very limited.

3. The ability of the parties to obtain documents, witness statements and other discovery is generally more limited in arbitration than in court proceedings.

4. The arbitrators do not have to explain the reason(s) for their award unless, in an eligible case, a joint request for an explained decision has been submitted by all parties to the panel at least 20 days prior to the first scheduled hearing date.

5. The panel of arbitrators will typically include a minority of arbitrators who were or are affiliated with the securities industry.

6. The rules of some arbitration forums may impose time limits for bringing a claim in arbitration. In some cases, a claim that is ineligible for arbitration may be brought in court.

7. The rules of the arbitration forum in which the claim is filed, and any amendments thereto, shall be incorporated into this Agreement.

Arbitration: I agree to resolve by binding arbitration any controversy that may arise between me and PB&T, PIMS or any of their affiliates (collectively “Prudential”) relating in any way to my relationship with Prudential, any account held with Prudential, or any service provided by Prudential to me. This arbitration agreement includes any controversy involving transactions of any kind made on my behalf by or through Prudential, or the performance, construction or breach of this Agreement or any other written agreement between Prudential and me. Such arbitration will be conducted in accordance with the rules then in effect of FINRA—unless the rules of another self-regulatory organization to which PIMS is subject mandate arbitration before that organization, in which case the arbitration will be conducted in accordance with the rules then in effect of that organization. I make this arbitration agreement on behalf of myself and my heirs, administrators, representatives, executors, successors, assigns and together with all other persons claiming a legal or beneficial interest in my retirement and brokerage accounts. Any award of the arbitrator or a majority of the arbitrators will be final and binding, and judgment on such award may be entered in any court having jurisdiction. This arbitration provision will be enforced and interpreted exclusively in accordance with applicable federal laws of the United States, including the Federal Arbitration Act. Any costs, attorneys’ fees or taxes involved in confirming or enforcing the award will be fully assessed against and paid by the party resisting confirmation or enforcement of said award.

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IMPORTANT CONSIDERATIONSThe decision to roll over from your Plan to an IRA needs careful consideration of the following factors:

IRA Rollover Decision

I understand that I typically have four choices (and may engage in a combination of these options) when considering what to do with my former employer’s plan: 1. Leave the money in my former employer’s plan if permitted2. Roll over the assets to my new employer’s plan if one is available and rollovers are permitted3. Roll over to an IRA 4. Cash out the account value

I understand that each choice offers advantages and disadvantages depending on my financial needs and that consideration should be given to certain factors based on those needs.

Investment Options

I understand that an IRA may allow me to select from a broader range of investment options than my former employer’s plan. I also understand that if I remain in my former employer’s plan, the investment choices are selected by a party that has a fiduciary obligation to act in my best interest. I understand that the Prudential SmartSolution IRA is not affiliated with any employer-sponsored plan or plan sponsor, and a rollover to an IRA means I am no longer part of an employer-sponsored plan. Once assets are rolled over to an IRA, they normally cannot be rolled back to a former employer’s plan.

Penalty-Free Withdrawal

I understand that I can typically withdraw money from an IRA at any time, although a penalty may apply. I understand that if I leave my job between age 55 and 59½, I may be able to take penalty-free withdrawals from a plan. In contrast, penalty-free withdrawals generally may not be made from an IRA until age 59½. It also may be easier to borrow from a plan than from an IRA.

Protection from Creditors and Legal Judgments

I understand that plan assets generally have unlimited protection from creditors under federal law, while IRA assets are protected in bankruptcy proceedings only. State laws vary in the protection of IRA assets in lawsuits.

Required Minimum Distributions

I understand that once I reach the age of 70½, the rules for both plans and IRAs require the periodic withdrawal of certain minimum amounts known as the required minimum distribution. If I am still working at age 70½, generally I am not required to make the required minimum distributions from my current employer’s plan—which may be advantageous for me if I work into my 70s.

Employer Stock

If I hold significantly appreciated employer stock in a plan, I should consider the negative tax consequences of rolling the stock to an IRA. If employer stock is transferred in-kind to an IRA, stock appreciation will be taxed as ordinary income upon distribution.

The tax advantages of retaining employer stock in a non-qualified account should be balanced with the possibility that I may be excessively concentrated in employer stock. It can be risky to have too much employer stock in my retirement account, and it may be advisable to liquidate the holdings and roll over the value to an IRA, even if it means losing long-term capital gains treatment on the stock’s appreciation.

Fees and Expenses

I understand that I may have the option to maintain my account balance under my former employer’s plan instead of rolling my account balance to an IRA, and that the fees associated with remaining in the plan will be different from the fees of the Prudential SmartSolution IRA. Both employer plans and IRAs typically involve investment-related expenses and plan or account fees. I understand that I may request a comparison of fees between my former employer’s plan and a Prudential SmartSolution IRA.

Investment-related expenses may include sales loads, commissions, the expenses of any mutual funds in which assets are invested and investment advisory fees. Plan fees typically include plan administrative fees such as recordkeeping, compliance, trust fees and fees for services. IRA account fees may include administrative, account set-up and custodial fees.

I understand that for additional questions or explanations I can contact Prudential Retirement at 877-778-2100 on (1) compensation, (2) investment options, (3) penalty-free withdrawals, (4) protection from creditors and legal judgments, (5) required minimum distributions, (6) employer stock and (7) fees and expenses.

I understand that the variable annuity with the Prudential IncomeFlex benefit is a part of the Prudential SmartSolution IRA and, if I select this option, I have reviewed the terms of the annuity and its prospectus.

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FRAUD DISCLOSURE

WARNING: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance and/or statement of claim that contains any materially false information, or who conceals information concerning any material fact for the purpose of misleading, commits a fraudulent insurance act under the laws of certain states. A fraudulent insurance act is a crime and subjects such person to criminal and civil penalties. In some states, the false or concealed information does not need to be “material” to result in a fraudulent insurance act.

• Colorado Residents: In addition to the notice above, any insurance company or agent of an insurance company who knowingly provides false, incomplete or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies.

• District of Columbia and Rhode Island Residents: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

• Florida Residents: Any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony of the third degree.

• Maryland Residents: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

• Oregon and Virginia Residents: This notice does not apply to residents of Oregon and Virginia.

Applicant’s Signature ______________________________________________ Date _____________________________

CONSENT OF SPOUSE: (To be used in community property states when spouse is not the sole Primary Beneficiary). I consent to the Beneficiary Designation in Section 4. By signing this consent, I intend to change the portion (if any) of this IRA, which is community property of my spouse.

Signature of Spouse _______________________________________________ Date _____________________________

Acknowledgment by PIMS Supervisory Principal Signature __________________________________________________________ Date ______________________________

Registered Representative’s Signature __________________________________________________________ Date ______________________________

SECURITIES PRODUCTS ARE NOT FDIC INSURED/NOT BANK DEPOSITS/MAY LOSE VALUE.

For informational or educational purposes only. This material is not intended as advice or recommendation about investing or managing your retirement savings. By sharing it, Prudential Retirement is not acting as your fiduciary as defined by the Department of Labor’s Fiduciary rule or otherwise. If you need investment advice, please consult with a qualified professional.

Investors should consider the contract and the underlying portfolio’s investment objectives, risks, charges and expenses carefully before investing. This and other important information is contained in the prospectuses, which can be obtained by calling your Financial Professional or logging in to the Prudential Online Retirement Center. You should read the prospectuses carefully before investing.

PruSecure is a group annuity product issued by The Prudential Insurance Company of America, Newark, NJ and is backed by the full faith and creditworthiness of the issuer. PruSecure is not available in Montana, Nevada, Utah, the Commonwealth of Puerto Rico, Guam or the U.S. Virgin Islands.

Securities products and services are offered by Prudential Investment Management Services LLC (PIMS), Newark, NJ, a Prudential Financial company. Member FINRA/SIPC.

The Prudential Retirement Security Annuity III and IV are variable annuities issued by Prudential Retirement Insurance and Annuity Company (PRIAC), Hartford, CT and distributed by Prudential Investment Management Services LLC, Newark, NJ (Member SIPC). Both are Prudential Financial companies, and each is solely responsible for their respective financial condition and contractual obligations. The Prudential IncomeFlex Target Asset Allocation Portfolio is a variable investment option offered under the annuity. Eligible investors may purchase the annuity through a Prudential SmartSolution IRA. Annuity contracts contain exclusions, limitations, reductions of benefits and terms for keeping them in force. Contract forms: ALC-TGWB-2011-NR, ALC-408-TGWB-II-2011-NR and state variations thereof. ALC-408-TGWB-2011-ROTH, ALC-408-TGWB-II-2011-ROTH and state variations thereof.

Annuities: Not insured by FDIC or any Federal Government Agency; May Lose Value; No Bank Guarantee. Variable annuities are suitable for long-term investing, particularly retirement savings.

© 2018 Prudential Financial, Inc. and its related entities. Prudential, the Prudential logo, the Rock symbol and Bring Your Challenges are service marks of Prudential Financial, Inc. and its related entities, registered in many jurisdictions worldwide.

6 C o n fi r m a t i o n o f e x i s t i n g c o v e r a g ePlease check one:

I do have existing life insurance or annuity contracts. (If you check this box, you must complete Section 7—“Important Notice: Replacement of Life Insurance or Annuities” even if you are not replacing any existing insurance coverage or annuity contract.)

I do not have existing life insurance policies or annuity contracts.

Have you had an exchange of any deferred variable annuity within the past 36 months?

Yes

No

If yes:

• Original annuity (company and contract) __________________________________________________________________________

• Replaced annuity (company and contract) _________________________________________________________________________

• Is it related to this transaction? ________________________________________________________________________________

• Amount of transaction ______________________________________________________________________________________

7 I m p o r t a n t n o t i c e : re p l a c e m e n t o f l i f e i n s u r a n c e o r a n n u i t i e sThis document must be signed by the applicant and the producer, if there is one, and a copy left with the applicant.

I do not want this notice read aloud to me.

_________ Applicants must initial only if they do not want this notice read aloud.If you are replacing an existing policy or contract, no later than 30 days after the new policy or annuity contract is delivered to you, you may return it to us or your agent and receive an unconditional full refund of all premiums paid on it, including any policy fees or charges, less the amount of any payment(s) we may have already made. If you are returning a variable policy or annuity contract, you will receive the cash surrender value provided under the policy or contract plus the fees and other charges deducted from the gross premiums or considerations, less the amount of any payment(s) we may have already made.

A replacement may not be in your best interest, or your decision could be a good one. You should make a careful comparison of the costs and benefits of your existing policy or contract and the proposed policy or contract. One way to do this is to ask the company or agent that sold you your existing policy or contract to provide you with information concerning your existing policy or contract. This may include an illustration of how your existing policy or contract is working now and how it would perform in the future based on certain assumptions. Illustrations should not, however, be used as a sole basis to compare policies or contracts. You should discuss the following with your agent and determine whether replacement or financing your purchase makes sense:

PREMIUMS:➣ Are they affordable?➣ Could they change?➣ You’re older—are premiums higher for the proposed new policy?➣ How long will you have to pay premiums on the new policy? On the old policy?

POLICY VALUES:➣ New policies usually take longer to build cash values and to pay dividends.➣ Acquisition costs for the old policy may have been paid; you will incur costs for the new one.➣ What surrender charges do the policies have?➣ What expense and sales charges will you pay on the new policy?➣ Does the new policy provide more insurance coverage?

10


11


INSURABILITY:➣ If your health has changed since you bought your old policy, the new one could cost you more, or you could be turned down.➣ You may need a medical exam for a new policy.➣ Claims on most new policies for up to the first two years can be denied on inaccurate statements.➣ Suicide limitations may begin anew on the new coverage.

YOU ARE KEEPING THE OLD POLICY AS WELL AS THE NEW POLICY:➣ How are premiums for both policies being paid?➣ How will the premiums on your existing policy be affected?➣ Will a loan be deducted from death benefits?➣ What values from the old policy are being used to pay premiums?

IF YOU ARE SURRENDERING AN ANNUITY OR INTEREST SENSITIVE LIFE PRODUCT:➣ Will you pay surrender charges on your old contract?➣ What are the interest rate guarantees for the new contract?➣ Have you compared the contract charges or other policy expenses?

OTHER ISSUES TO CONSIDER FOR ALL TRANSACTIONS:➣ What are the tax consequences of buying the new policy?➣ Is this a tax-free exchange? (See your tax advisor.)➣ Is there a benefit from favorable “grandfathered” treatment of the old policy under the federal tax code?➣ Will the existing insurer be willing to modify the old policy?➣ How does the quality and financial stability of the new company compare with your existing company?

You are contemplating the purchase of a life insurance policy or annuity contract. In some cases this purchase may involve discontinuing or changing an existing policy or contract. If so, a replacement is occurring. Financed purchases are also considered replacements.

A replacement occurs when a new policy or contract is purchased and, in connection with the sale, you discontinue making premium payments on the existing policy or contract, or an existing policy or contract is surrendered, forfeited, assigned to the replacing insurer or otherwise terminated or used in a financed purchase.

A financed purchase occurs when the purchase of a new life insurance policy involves the use of funds obtained by the withdrawal or surrender of or by borrowing some or all of the policy values—including accumulated dividends—of an existing policy to pay all or part of any premium or payment due on the new policy. A financed purchase is a replacement.

You should carefully consider whether a replacement is in your best interest. You will pay acquisition costs, and there may be surrender costs deducted from your policy or contract. You may be able to make changes to your existing policy or contract to meet your insurance needs at less cost. A financed purchase will reduce the value of your existing policy and may reduce the amount paid upon the death of the insured.

We want you to understand the effects of replacements before you make your purchase decision. We ask that you answer the following questions and consider the questions on the back of this form.

1. Are you considering discontinuing making premium payments, surrendering, forfeiting, assigning to the insurer or otherwise terminating your existing policy or contract?

Yes

No

2. Are you considering using funds from your existing policies or contracts to pay premiums due on the new policy or contract?

Yes

No

12

If you answered “Yes” to either of the previous questions, list each existing policy or contract you are contemplating replacing (include the name of the insurer, the insured or annuitant and the policy or contract number if available) and whether each policy or contract will be replaced or used as a source of financing:

INSURER NAME PLAN/CONTRACT/POLICY # INSURED OR ANNUITANT REPLACED (R) OR FINANCING (F)

1.

2.

3.

Make sure you know the facts. Contact your existing company or its agent for information about the old policy or contract. (If you request one, an in-force illustration, policy summary, or available disclosure documents must be sent to you by the existing insurer.) Ask for and retain all sales material used by the agent in the sales presentation. Be sure that you are making an informed decision.

The existing policy or contract is being replaced because:

______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

I certify that the responses herein are, to the best of my knowledge, accurate.

Applicant’s Signature ___________________________________________________________________________________

Printed Name _____________________________________________________________ Date ______________________

I have reviewed with the applicant any annuity replacement activity within the preceding 36 months. I acknowledge I have reviewed with the applicant 1) the variable annuity with the Prudential IncomeFlex benefit and 2) (if applicable) the benefits, features and costs of this option.

Producer’s Signature ___________________________________________________________________________________

Printed Name _____________________________________________________________ Date ______________________

SECURITIES PRODUCTS ARE NOT FDIC INSURED/NOT BANK DEPOSITS/MAY LOSE VALUE.

For informational or educational purposes only. This material is not intended as advice or recommendation about investing or managing your retirement savings. By sharing it, Prudential Retirement is not acting as your fiduciary as defined by the Department of Labor’s Fiduciary rule or otherwise. If you need investment advice, please consult with a qualified professional.

Investors should consider the contract and the underlying portfolio’s investment objectives, risks, charges and expenses carefully before investing. This and other important information is contained in the prospectuses, which can be obtained by calling your Financial Professional or logging in to the Prudential Online Retirement Center. You should read the prospectuses carefully before investing.

PruSecure is a group annuity product issued by The Prudential Insurance Company of America, Newark, NJ and is backed by the full faith and creditworthiness of the issuer. PruSecure is not available in Montana, Nevada, Utah, the Commonwealth of Puerto Rico, Guam or the U.S. Virgin Islands.

Securities products and services are offered by Prudential Investment Management Services LLC (PIMS), Newark, NJ, a Prudential Financial company. Member FINRA/SIPC.

The Prudential Retirement Security Annuity III and IV are variable annuities issued by Prudential Retirement Insurance and Annuity Company (PRIAC), Hartford, CT and distributed by Prudential Investment Management Services LLC, Newark, NJ (Member SIPC). Both are Prudential Financial companies, and each is solely responsible for their respective financial condition and contractual obligations. The Prudential IncomeFlex Target Asset Allocation Portfolio is a variable investment option offered under the annuity. Eligible investors may purchase the annuity through a Prudential SmartSolution IRA. Annuity contracts contain exclusions, limitations, reductions of benefits and terms for keeping them in force. Contract forms: ALC-TGWB-2011-NR, ALC-408-TGWB-II-2011-NR and state variations thereof. ALC-408-TGWB-2011-ROTH, ALC-408-TGWB-II-2011-ROTH and state variations thereof.

Annuities: Not insured by FDIC or any Federal Government Agency; May Lose Value; No Bank Guarantee. Variable annuities are suitable for long-term investing, particularly retirement savings.


Prudential RetirementPO Box 5320Scranton, PA 18505-5320

}RETURN STANDARD MAIL TO:Prudential Retirement30 Scranton Office ParkScranton, PA 18507

}RETURN OVERNIGHT MAIL TO: 877-493-9854}FAX TO:

ROFM043_0003 Printed 07/2018

Prudential SmartSolution IRA Investment Selection, Appendix A

Fund Lineup Share Class Ticker Allocation %

RETIREMENT INCOME

PGIM IncomeFlex® Target 60/40 Allocation Portfolio (formerly known as Prudential IncomeFlex® Target 60/40 Allocation Portfolio)*, 1, 2 R6 N/A

Mon

ey

Mar

ket MONEY MARKET

Goldman Sachs Financial Square Government Institutional FGTXX

Western Asset Institutional Government Reserves Institutional INGXX

Inte

rmed

iate

Fix

ed In

com

e

STABLE VALUE

PruSecure (GIA)3 N/A N/A

INTERMEDIATE-TERM BOND

iShares U.S. Aggregate Bond Index K WFBIX

Loomis Sayles Core Plus Bond N NERNX

PGIM Total Return Bond (formerly known as Prudential Total Return Bond)* R6 PTRQX

Western Asset Core Plus Bond IS WAPSX

HIGH YIELD

JPMorgan High Yield I OHYFX

PGIM High Yield (formerly known as Prudential High Yield)* R6 PHYQX

WORLD BOND

PIMCO Foreign Bond (USD-Hedged) Institutional PFORX

TIPS

TREASURY INFLATION-PROTECTED SECURITIES (TIPS)

T. Rowe Price Inflation Protected Bond I TIIPX

Western Asset Inflation Indexed Plus Bond IS WAFSX

US L

arge

-Cap

LARGE GROWTH

American Century Growth Investor TWCGX

Columbia Large Cap Growth Institutional 3 CGFYX

Eaton Vance Growth I ELCIX

MFS® Growth R6 MFEKX

PGIM Jennison Growth (formerly known as Prudential Jennison Growth)* Z PJFZX

T. Rowe Price Growth Stock No Load PRGFX

LARGE BLEND

iShares S&P 500 Index K WFSPX

iShares Total U.S. Stock Market Index K BKTSX

PGIM QMA Large-Cap Core Equity (formerly known as Prudential QMA Large Cap Core Equity)* R6 PTMQX

PGIM QMA Stock Index (formerly known as Prudential QMA Stock Index)* R6 PDSIX

LARGE VALUE

Goldman Sachs Large Cap Value Institutional GSLIX

Hotchkis & Wiley Large Cap Value I HWLIX

LSV Value Equity Institutional LSVEX

Touchstone Value Y TVLYX

US M

id-C

ap

MID GROWTH

Artisan Mid Cap Institutional APHMX

Touchstone Mid Cap Growth Y TEGYX

MID BLEND

Hartford MidCap Value Y HMVYX

iShares Russell Mid-Cap Index K BRMKX

MID VALUE

Harbor Mid Cap Value Institutional HAMVX

PGIM QMA Mid-Cap Value (formerly known as Prudential QMA Mid-Cap Value)* R6 PMVQX

Fund Lineup Share Class Ticker Allocation %

US S

mal

l-Cap

SMALL GROWTH

Brown Advisory Small-Cap Growth Institutional BAFSX

UBS US Small Cap Growth P BISCX

Victory RS Small Cap Growth Y RSYEX

SMALL BLEND

AMG Managers Silvercrest Small Cap I ACRTX

iShares Russell 2000 Small-Cap Index K BDBKX

SMALL VALUE

JPMorgan Small Cap Value I PSOPX

Victory Integrity Small-Cap Value Y VSVIX

Inte

rnat

iona

l Equ

ity

FOREIGN LARGE GROWTH

Artisan International Institutional APHIX

FOREIGN LARGE BLEND

Hartford International Opportunity Y HAOYX

iShares MSCI Total International Index K BDOKX

Lazard International Equity Institutional LZIEX

WORLD STOCK

MFS® Global Equity R6 MWEMX

Oppenheimer Global I OGLIX

DIVERSIFIED EMERGING MARKET

Parametric Emerging Markets Institutional EIEMX

Non-

Trad

ition

al

SECTOR FUNDS

AQR Risk-Balanced Commodities Strategies I ARCIX

PIMCO CommoditiesPLUS® Strategy Institutional PCLIX

American Century Real Estate Investor REACX

Cohen & Steers Real Estate Securities I CSDIX

Emerald Banking and Finance Institutional HSSIX

Janus Henderson Global Life Sciences I JFNIX

Janus Henderson Global Technology I JATIX

PGIM Global Real Estate (formerly known as Prudential Global Real Estate)* R6 PGRQX

T. Rowe Price New Era I TRNEX

Targ

et D

ate

TARGET-DATE FUNDS

Prudential Day One® Income Fund R6 PDAJX

Prudential Day One® 2010 Fund R6 PDBJX

Prudential Day One® 2015 Fund R6 PDCJX

Prudential Day One® 2020 Fund R6 PDDJX

Prudential Day One® 2025 Fund R6 PDEJX

Prudential Day One® 2030 Fund R6 PDFJX

Prudential Day One® 2035 Fund R6 PDGJX

Prudential Day One® 2040 Fund R6 PDHJX

Prudential Day One® 2045 Fund R6 PDIJX

Prudential Day One® 2050 Fund R6 PDJJX

Prudential Day One® 2055 Fund R6 PDKJX

Prudential Day One® 2060 Fund R6 PDLJX

Investment allocations on these pages MUST total 100%. 100%

* As of Jan. 30, 2016 Prudential Investment Management has changed its name to Prudential Global Investment Management (PGIM). Effective June 11, 2018, retail domestic fund names no longer include “Prudential” and are branded “PGIM.” This name change does not affect the management, symbols or CUSIPs of the funds on the platform.

1 Prudential Retirement Security Annuity III: Effective Oct. 24, 2013, you are allowed to roll over existing IncomeFlex Target balances only; the Annuity will be closed to any additional purchase payments after that date.

2Prudential IncomeFlex Target is not available for investment to residents of Alaska, Florida, Louisiana, Maine, Nevada, New Hampshire and Texas.3PruSecure is not available for investment to residents of Montana, Nevada, Utah, the Commonwealth of Puerto Rico, Guam and the U.S. Virgin Islands.

Investors should consider the contract and the underlying portfolio’s investment objectives, risks, charges and expenses carefully before investing. This and other important information is contained in the prospectuses, which can be obtained by calling your financial professional at 877-PRU-2100 (877-778-2100) or visiting the mutual fund company’s website directly. You should read the prospectuses carefully before investing. You can lose money by investing in securities.

For additional information on the available funds, please visit prudential.com/prs or contact your financial professional at 877-778-2100.

Note that the investment percentages selected above will also apply to future investments made to your Prudential SmartSolution IRA. You are free to modify the allocations to your Prudential SmartSolution IRA at any time.

I understand that in the event a fund is closed to new contributions based on our ongoing assessment process, we will ask you to change your investment allocations so new contributions are not added to the fund. If you do not select a new fund for the allocation, we will default the future allocation percentage to the default fund (Western Asset Institutional Government Reserves).

I understand that Prudential SmartSolution IRA investments are not insured by the FDIC, are not deposits or other obligations of any bank and are subject to investment risk, including possible loss of principal invested.

I understand that, some of the investments, both mutual funds and interests in group annuities, available as investments in the Prudential SmartSolution IRA are offered by Prudential affiliates, and that the list of investments is subject to change.

Prudential Retirement Security Annuity I, II, III and IV and the Prudential IncomeFlex Benefit:

I understand that the Prudential IncomeFlex benefit is a feature of the variable annuity contract issued by Prudential Retirement Insurance and Annuity Company. I agree to be bound by the terms and conditions of the variable annuity as set forth in the annuity contract or certificate that I receive once my initial annuity purchase payment is accepted.

I understand that by selecting underlying investment options with the Prudential IncomeFlex benefit, I am investing in a variable annuity. I understand the fees for variable annuities will differ and may be higher than fees charged in my retirement plan or by other available investments. I also understand there is a $20,000 minimum initial purchase payment required to purchase a variable annuity with the Prudential IncomeFlex benefit. To meet this minimum initial purchase payment, in addition to my rollover from a qualified plan, I may be able to consolidate other outside qualified money.

I understand that, with respect to the Prudential Retirement Security Annuity I and III, subsequent purchase payments are not permitted (i.e. purchase payments made after the initial purchase payment). For Prudential Retirement Security Annuity I, II, III and IV, please consult the prospectus for details concerning the Prudential IncomeFlex benefit. With respect to the Prudential Retirement Security Annuity, the prospectus, among other factors, details the conditions under which the IncomeFlex benefit under your employment-based retirement plan is rolled over to the IncomeFlex benefit under the Prudential Retirement Security Annuity.


SMA002FMRE1_0003 Printed 08/01/2018

Prudential RetirementPO Box 5320Scranton, PA 18505-5320

}RETURN STANDARD MAIL TO:Prudential Retirement30 Scranton Office ParkScranton, PA 18507

}RETURN OVERNIGHT MAIL TO: 877-493-9854}FAX TO:

I have completed Appendix A and certify that the fund allocations I have selected equal 100%.

Applicant’s signature

Printed name Date

prudential smartsolution ira application and brokerage agreement

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