P R U D E N T I A L R E T I R E M E N T. I N T E L L I G E N T S O L U T I O N S , W O R K I N G F O R Y O U .
QUESTIONS?
Call Personal Retirement Services
at 888-244-6237
www.prudential.com/prs
IRA APPLICATION
Office F72
Choose Type of IRA
I elect that my IRA assets be considered a rollover contribution. I understand this election is required by the Internal Revenue Service to qualify
my contribution as a rollover contribution.
Rollover IRA
Traditional IRA
Roth IRA
Beneficiary IRA
1
Personal Information
Account Holder
Name
Social
Security No.
Home
Phone No.
Driver’s
License No.
or
Passport No.
Country
Date of Birth
Home
E-mail
State
Issue Date
Expiration Date
Expiration Date
Street
Address
City
State
Zip
Code
Legal
Address
(If different from above, or if street address is a P.O. box, you must provide a legal street address.)
City
State
US Citizen
Other
Marital Status: Single
Zip
Code
Non-Resident Alien? (If yes, W-8 is required.)
Married
Yes
No
Number of Dependents
Additional Information
Occupation
Employed by
Business Phone Number
Business Address
City
State
Zip
Code
If self-employed, what is the nature of your business?
If not employed, are you retired, a student, etc.?
Check here if you are a Prudential Financial employee.
ACCOUNT CARRIED WITH NATIONAL FINANCIAL SERVICES LLC, MEMBER NYSE/SIPC.
FOR PRUDENTIAL RETIREMENT USE ONLY:
Office
F72
Reg. Rep. No.
Account No.
Date Account
Opened
Do you have an existing account with Prudential Investment Management Services LLC?
Yes
No
Please notify us 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). Without this information we cannot identify and link related accounts held outside and in some cases, held within Prudential Investment
Management Services LLC. The investor may not realize the full breakpoint opportunity available without this information.
Account Number(s)
Affiliation Disclosure
Are you affiliated with or employed by a member firm of a stock exchange or the NASD, Inc.; are you a senior officer of a bank, S&L, insurance company,
registered investment company, registered investment advisory firm; 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 and position
Are you a director, a 10 percent shareholder, or a policy-making executive officer of a publicly traded company?
Yes
2
No
If yes, list company
Client Profile Information
This portion of the application 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 application 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 application is incomplete.
Income
Net Worth
Check one box. See definitions below if you have any questions.
Check one box in each column. See definitions below if you have any questions.
Ranges
Ranges
Annual Income
(all sources)
$0–24,999
$0–49,999
$25,000–49,999
$50,000–99,999
$50,000–99,999
$100,000–499,999
$100,000 +
Net Worth
(assets minus liabilities)
$500,000 +
Owner’s Tax Bracket: _______% (Approximate federal income tax bracket, based on previous year’s tax return.)
Definitions
Annual Income (all sources):
Annual gross income, 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. 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.
Liquid Net Worth
(exclude non-liquid assets)
Investment Objectives
Please rank your investment objectives as they relate to the assets in your brokerage account from 1 (most important) to 5 (least important).
Preservation of Capital
Income
Capital Appreciation
Speculation
Trading Profits
Risk Tolerance
Please select the description that best represents your investment approach to this account.
Conservative
Prefer little risk and low volatility in return for accepting potential lower 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.
Investment Experience
Please indicate your years of experience with the following investment types.
_____________________________________________ Equities
_____________________________________________ Options
_____________________________________________ Bonds
_____________________________________________ Variable Contracts
_____________________________________________ Mutual Funds
_____________________________________________ Limited Partnerships
Time Horizon
Please 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
Source of Funds for this Account
Please indicate the source of funds for this IRA account below. (If making a contribution by check, please skip to Section 4 and select the apropriate choice.)
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 application.
Plan maintained by an external service provider (NOT Prudential).
Individual Retirement Account (IRA).
3
How Will This IRA Be Initially Funded? (Choose one)
Contribution check enclosed for
Check enclosed for
$
$
for tax year
to be treated as a 60-day rollover from another retirement plan or IRA.
Direct transfer of an IRA from another financial institution. (Please complete and submit a transfer form.*)
Direct rollover from a tax-qualified retirement plan.
Date when you plan to receive your distribution
Name of company sponsoring former tax-qualified plan
Approximate total value of cash and/or securities being rolled over
$
Conversion of assets from a Prudential Investment Management Services LLC Traditional or Rollover IRA to a Prudential Investment Management Services LLC Roth IRA
Will the funds being converted be taxable or non-taxable?
If funds being converted are non-taxable, specify amount of non-taxable funds
$
Conversion of assets from a Prudential Retirement® IRA for a deceased individual to Prudential Investment Management Services LLC beneficiary
IRA account Number (of deceased individual’s IRA)
Other (please specify)
* Specific forms can be obtained by calling Personal Retirement Services at 888-244-6237.
4
Investment Selection
If an investment selection is not made, your assets will be invested in the Money Account.
OPTION 1—If you would like to allocate portions of your assets to specific funds or securities, please use the area below to specify the securities, and the percentage of
your assets you’d like to invest. If individual equities or bonds are indicated, our policy is to verbally confirm these instructions prior to entering the orders. Our success in
contacting you may delay the entering of the orders. These instructions only apply to your initial deposit and do not apply to future contributions.
%
%
%
%
%
%
Please read your prospectus carefully before investing.
OPTION 2— If you would like your assets to be professionally managed by a registered investment advisor, please complete a Compass Client Profile and
Questionnaire and return it with this application. To obtain a Compass kit, call 888-244-6237. Minimum initial deposit is $50,000.
Check here if funds are being transferred in kind from another account.
5
Beneficiary Designation
Please select a Primary Beneficiary(ies). Percentages must equal 100 percent. You may also select a Contingent Beneficiary(ies).
These percentages must also equal 100 percent.
Primary Beneficiary
Contingent Beneficiary
Name
Name
Relationship
Relationship
Address
Address
City
City
State
Zip Code
State
Social Security No.
Zip Code
Social Security No.
%
Date of Birth
%
Date of Birth
Please use whole percentages—must total 100 percent
Please use whole percentages—must total 100 percent
Primary Beneficiary
Contingent Beneficiary
Name
Name
Relationship
Relationship
Address
Address
City
City
State
Zip Code
State
Social Security No.
Zip Code
Social Security No.
%
Date of Birth
Please use whole percentages—must total 100 percent
Date of Birth
%
Please use whole percentages—must total 100 percent
The benefits payable hereunder shall be paid in equal shares (or 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 percentages indicated above) to the Contingent Beneficiary who survives the Account Holder. If
percentages shown above for surviving beneficiaries do not total 100 percent, benefits will be prorated in proportion to percentages shown.
This Beneficiary Designation is subject to all of the 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 70 1⁄2, 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.
Consent of Spouse
(To be used in community property states when spouse is not sole Primary Beneficiary). I consent to the above Beneficiary Designation. By signing this consent, I intend to
change the portion (if any) of this IRA which is community property of my spouse.
Date
Signature of Spouse
6
Signature
I am authorized to enter into this Agreement and have obtained and will provide you with all necessary authorizations from third parties to open accounts and effect
securities transactions under this Agreement. I will be the owner of all securities purchased, held, and sold by me through you, or will otherwise have the authority
to purchase, hold, or sell such securities. I understand that you entered into an agreement with National Financial Services LLC (NFS) to execute and clear securities
transactions in my Securities Account. I further understand and agree that NFS will carry and maintain my Securities Account, except as may otherwise be provided
in this Agreement. I understand and agree that, for our mutual protection, you and NFS may record any of our telephone conversations without further notice. I also
understand that all transactions shall be subject to rules, regulations, customs, and usages of the exchange, market, or clearinghouse where executed, and to all
applicable federal and state laws and regulations. I will not buy, sell, or liquidate any securities of a corporation of which I am an affiliate, or sell or liquidate any
restricted securities, except in compliance with applicable laws and regulations and with notice, to you, that the securities are restricted.
I understand that available free credit balances in my account will be automatically invested or deposited in a Money Account. This Money Account may be a money
market mutual fund, an FDIC-insured bank deposit (which may be a deposit with Prudential Bank & Trust, FSB, an affiliate of Prudential Retirement) or such other
arrangement as you may establish from time to time. I agree that you may, at your discretion, change the Money Account by providing me with advance written notice
of such change. In the event that you elect to change the Money Account, I authorize you to redeem or withdraw any funds held in the prior Money Account and reinvest
them into the new Money Account.
Under penalties of perjury, I certify that the above information (including my Social Security number) is correct. (NOTE: failure to provide correct Social Security number
will subject my account to withholding.) I hereby agree to participate in the Custodial Account offered by the Custodian. I acknowledge receipt of a copy of the Custodial
Agreement under which this Individual Retirement Account is established, a copy of this Application and Customer Agreement, and a copy of the Disclosure Statement
issued with respect to this Individual Retirement Account. I direct that my contribution be invested as indicated, and I direct that all benefits upon my death be paid as
indicated. In the event that this is a rollover contribution, the undersigned hereby irrevocably elects, pursuant to the requirements of §1.402(a)(5)-1T of the IRS regulations,
to treat this contribution as a rollover contribution.
I have reviewed the information contained on this application and attest to the accuracy thereof. I also acknowledge that I have read and agree to the terms and conditions
of the Customer Agreement.
I understand that Prudential Retirement IRA investments are not insured by the FDIC, are not deposits or other obligations, unless stated otherwise, of any bank, and are
subject to investment risks including possible loss of principal invested.
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 identify.
Brokerage Account Fees
I understand that this IRA account will be charged the following fees:
The “Select” Platform of Mutual Funds
Several mutual fund families have agreed to allow Prudential Investment Management Services LLC (“Prudential”) to offer their funds to Prudential’s IRA customers at net
asset value, and to waive any traditional sales charges or “loads” that might otherwise apply under the fund’s prospectus. A list of these fund families, which are known
as the Select Platform, is available in the current version of the Brokerage Services Investor Toolkit. To obtain a copy, please call calling 1-888-244-6237 or visit
www.prudential.com/prs. The fees related to investments in these funds are described below.
Transaction Fee:
A one-time transaction fee of 1.75% of principal ($75 minimum, $350 maximum) will apply to all purchases of SelectPlatform mutual funds. This fee will not apply
to distributions from funds, exchanges among funds within the same SelectPlatform fund family, or to fund dividends or earnings. It will apply to new IRA contributions
(including rollovers), to amounts that are liquidated from another IRA investment (such as an equity or bond) or from any mutual fund outside the same fund family and
used to purchase SelectPlatform mutual fund shares.
Finders Fees:
Prudential provides various services in distributing and administering our customers’ shares of mutual funds. In return for assistance in providing these services, Prudential
receives additional compensation from the mutual fund company, which takes the form of a “finder’s fee”. These payments are in addition to commissions, annual service
or distribution fees (known as 12b-1 fees) and other fees and expenses disclosed in a fund’s prospectus fee table and described in the fund’s prospectus. These payments
are made by the company that distributes the mutual fund, and are not paid from the assets of the fund itself. Therefore, they would not appear in the expense table under
the fund’s prospectus. None of these finder’s fees are paid to any Prudential registered representative, and Prudential’s registered representatives do not receive any
greater or lesser compensation for the sale of mutual funds for which Prudential receives revenue sharing payments.
While the arrangements may vary over time, the typical finder’s fee is up to 100 basis points (1.0%) on new contributions to the fund, and is paid to Prudential only at the
time that the contribution was made. For example, if a customer made a $10,000 contribution to a fund that pays a 100 basis point finder’s fee, Prudential would receive
a one-time payment of $100. Not all mutual fund families on the SelectPlatform currently pay a finder’s fee to Prudential. For a list of funds that pay a finder’s fee, and the
amount paid for each fund, please call 1-888-244-6237.
Other Fees Reflected in the Fund’s Value:
As mentioned above, Prudential and other firms may also receive administrative fees, sub-transfer agent fees or Section 12b-1 fees or other fees that are described in
the applicable fund’s prospectus and are listed in the expense table within the prospectus. Also, the fund may charge management fees or impose a contingent charge
for withdrawals in certain circumstances. Again, these fees are described in the applicable fund’s prospectus, which you should read carefully.
While this will vary, the typical fees payable to Prudential in accordance with the prospectus amount to 25 to 50 basis points (0.25% to 0.50%), paid annually during
the time those assets remain invested with that fund family. For a breakdown, by mutual fund, of the fees paid to Prudential under the fund’s prospectus, please call
1-888-244-6237.
Mutual Funds Outside the “Select” Platform
In addition to the funds on the SelectPlatform, other mutual funds are available for investment within an IRA account. The fees associated with those other funds are
described in the applicable fund’s prospectus. For a breakdown, by mutual fund, of the fees paid to Prudential under the fund’s prospectus, please call 1-888-244-6237.
Other Brokerage Account Fees
The other annual or per-transaction fees (which could apply to mutual funds as well as to other investments, such as individual stocks or bonds) are described in the
Brokerage Pricing Guide that is in the Brokerage Services Investor Toolkit.
I understand that the Customer Agreement contains a pre-dispute clause (section 15 of the Customer Agreement, beginning on page 2) requiring all disputes
under this Agreement to be settled by binding arbitration. By signing below, customer acknowledges receiving a copy of this Agreement and agrees to be bound
by its terms and conditions.
Signature of
Account Holder
Date
Print Account
Holder Name
Date
FOR PRUDENTIAL RETIREMENT USE ONLY:
Signature of Registered
Representative
Date
Print Name of Registered
Representative
Date
Signature of Supervisory
Principal
Date
Print Name of Supervisory
Principal
Date
RETURN STANDARD MAIL TO
}
Prudential Retirement
Personal Retirement Services
P.O. Box 150476
Hartford, CT 06115-0492
RETURN OVERNIGHT MAIL TO
}
Prudential Retirement
Personal Retirement Services
280 Trumbull Street, Operations HO5R
Hartford, CT 06103
S E C U R I T I E S P R O D U C T S A R E N O T F D I C I N S U R E D / N O T B A N K D E P O S I T S / M AY LO S E VA LU E
Securities products and services are offered by Prudential Investment Management Services LLC (PIMS), Three Gateway Center, 14th Floor Newark, NJ 07102-4077. PIMS is a Prudential Financial
company. Member NASD/SIPC. Prudential Retirement is a Prudential Financial business. Prudential Retirement and Prudential Financial are registered service marks of The Prudential Insurance
Company of America, Newark, NJ and its affiliates.
280 Trumbull Street • Hartford, CT 06103
www.prudential.com/prs
RO.FM.011
Printed 12/2006
