Request for IRA Beneficiary Distribution
(Entity)
For assistance:
Clients (800) 225-1852
Pruco representatives (800) 542-7117
Financial professionals (888) 778-5471
Prudential Mutual Fund Services LLC ( PMFS)
a Prudential Financial company
Instructions
Use this form to request a distribution from an Individual Retirement Account (IRA) due to the death of an
IRA owner for which the beneficiary is a nonperson or entity, such as the owner's estate or trust or a
charitable organization. In addition to completing this form, we request an Affidavit of Domicile. An
Inheritance Tax Waiver may also be required, depending on the decedent's state of residence.
We have presented this information based on our understanding of the applicable tax laws. We suggest
that you consult with your tax adviser because neither we, nor our representatives, can provide tax advice.
You may consult IRS Publication 590 Individual Retirement Arrangements for additional information by
contacting the IRS Forms Distribution Center at (800) 829-3676 (TAX-FORM) or by downloading Publication
590 from www.irs.gov.
On these pages, I, my, you, and your refer to the account owner. We, us and our refers to PMFS.
Mailing
Instructions
Standard Prudential Mutual Fund Services LLC
mail to:
PO Box 9658
Providence, RI 02940
1
Deceased
IRA Owner
Information
Indicate the deceased IRA owner's account number, name, Social Security number, and date of death.
2
Current
Beneficiary
Information
Entity name, tax identification number, complete mailing address, and daytime and home telephone numbers.
3
Associated
Person
Identity
Verification
USA Patriot Act requirements – To help the government fight the funding of terrorism and money laundering
activities, Prudential Financial is required to obtain, verify, and record information on each person who
opens an account or beneficiary who inherits an IRA.
Overnight Prudential Mutual Fund Services LLC
mail to:
4400 Computer Drive
Westborough, MA 01581
Please be sure to review the Privacy Policy at the end of this application.
Important – The following information is required for each person associated with the account:
•
•
•
•
Name
Residence address
Date of birth
Taxpayer ID number (SSN or EIN)
If this information is not provided, we will be unable to complete your request. If we are unable to verify your
identity, Prudential Financial reserves the right to take any step we deem reasonable.
4
Beneficiary
Options
Option 1. Transfer the entity's interest into a new (separate) account for the benefit of the entity as named
in section 2 to begin receiving the required minimum distributions, as follows:
If the owner died prior to his or her required beginning date (RBD), which is April 1 of the year after he or
she reached age 70½, the balance of the account must be distributed by December 31 of the fifth year
following the year of the owner's death.
(continued)
MF1024C
Ed. 4/2011
Page 1 of 9
4
Beneficiary
Options
(continued)
If the owner died after his or her RBD, required distributions must begin by December 31 of the year following
the year of the owner's death (based on his or her life expectancy), using the age of the decedent as of
his/her birthday in the calendar year of his or her death and subtracting one year for each year thereafter.
If a trust is identified as a beneficiary, distributions are made payable to the trust and reported to the IRS
under the trust's tax identification number. The trustee(s) may choose to treat the trust beneficiaries as the
designated beneficiaries and supply to PMFS names and date of birth of the oldest beneficiary as of
September 30 by October 31 of the year following the year of the owner's death to PMFS. The accounts may
be separated for each trust beneficiary and payments to the trust may be based on the oldest trust
beneficiary's life expectancy.
Note: If you choose option 1, you must also complete section 6 for distribution instructions.
Option 2. Distribute the entity's entire interest in a lump sum payment, or reinvest directly into a new or
existing non-IRA account without sales charge. If you choose to reinvest into a non-IRA account, please
provide an existing fund/account number, or submit this form along with a new non-IRA application to
establish a new fund or account. Note: Distributions will be reported as taxable income for the year that the
distribution is made.
5
Decedent’s
Required
Minimum
Distribution
(RMD)
Information
Indicate if the IRA owner was age 70½ or older and satisfied his/her required minimum distribution (RMD)
in the current year.
6
New
Owner's
RMD
Information
Complete this section only if you selected beneficiary option 1 in section 4. Note: Distributions are generally
required to begin by December 31 following the year of the IRA owner's death.
7
Complete this section to request that payments be mailed to an address other than the address provided in
Special
section 2.
Mailing
Instructions
for
Distributions
8
Bank
Account
Information
Complete this section to request payments authorized in section 4 to be wired or electronically sent to your
bank account. Note: Amounts under $500 will not be wired and will be sent by check.
9
Tax
Withholding
Election
Indicate what percentage, if any, PMFS should withhold for income taxes.
We present this information based on our understanding of tax law. You may wish to consult with a tax or
legal adviser because neither we nor our representatives can provide tax or legal advice.
Federal and state income tax withholding. Federal and some state tax laws require us to withhold income
taxes from certain cash payments unless you elect out of withholding and in certain other circumstances.
We are required to withhold federal income taxes and certain state income taxes from the taxable portion
(continued)
MF1024C
Ed. 4/2011
Page 2 of 9
9
Tax
Withholding
Election
(continued)
of any withdrawal from a nonqualified annuity, an IRA, a Roth IRA, a Section 403(b) tax-deferred annuity, or
a Section 401(a) qualified plan.
If your withdrawal is from a Section 403(b) tax-deferred annuity or a Section 401(a) qualified plan, and is
an “eligible rollover distribution,” you will not be able to elect out of federal income tax withholding. Federal
taxes will be withheld at a 20 percent rate unless you elect to have your eligible rollover distribution directly
rolled over to an IRA or to another qualified plan. You will not be able to elect out of withholding if we are
notified that your taxpayer identification number (TIN) is incorrect.
Estimated tax and possible penalties. If you elect to have no income tax withheld from your withdrawal, or
if you do not have enough income tax withheld from your withdrawal, you may be responsible for payment
of estimated tax. You may incur penalties if your withholding and estimated tax payments are not sufficient.
You may be subject to IRS penalties, including fines and imprisonment, if you fail to provide your correct
taxpayer identification number (TIN), fail to report taxable interest or dividends on your tax return, or give
false tax information. You may also be subject to a 10 percent federal income tax penalty if you are under the
age of 59½ and you are taking a withdrawal.
10
Authorization You must have your signature medallion signature guaranteed in section 10 of the form.
and Signature
Guarantee
11
Tax
Certification
and
Signature
(Please sign
and date
where
indicated.
We cannot
process this
form without
your
signature.)
Taxpayer identification number and U.S. citizenship. You must include your TIN in section 11. If the account
owner is an individual, this is the Social Security number. If you are not sure which number to put on the form,
please refer to the chart below. You must state whether you are or are not a U.S. citizen. If you are not a U.S.
person (including resident alien), you must provide the country of which you are a citizen and submit the
applicable IRS Form W-8(BEN, ECI, EXP, IMY). In most situations, the IRS Form W-8BEN will be the
appropriate IRS Form W-8.
Use this table to determine the taxpayer identification number to include in section 11:
For this type of account ownership:
Individual
Joint (two or more individuals, including husband
and wife)
Custodian account of a minor (UGMA/UTMA)
Sole proprietorship
Revocable or Grantor Trust
For this type of account ownership:
Corporation
Association, club, religious, charitable, educational,
or other tax-exempt organization
Partnership
Broker or registered nominee
Valid trust, estate trust, or pension trust
Give Social Security number of:
Individual
Actual account owner: if combined funds, the
first individual on the account
Minor
Owner of business
Grantor
Give employer identification number of:
Corporation
Organization
Partnership
Broker or nominee
Legal entity (Do not furnish the identification number
of personal representative or trustee unless the legal
entity itself is not designated in the contract.)
Backup withholding. You must tell us if the IRS has notified you that you are subject to backup withholding
because you did not report all your taxable interest and dividends on your tax return. You are not subject to
backup withholding if you did not receive such a notice from the IRS, or if the IRS recently told you that
you are no longer subject to a backup withholding order. If you have been notified that you are subject to
backup withholding, please check the appropriate box in section 11.
If the account is held by a trustee as agent for an individual or by a grantor trust, the individual for whom
the account is held or the grantor must complete a substitute Form W-9 and attach it to this form in order
not to be subject to backup withholding.
MF1024C
Ed. 4/2011
Page 3 of 9
IRA Beneficiary Distribution Form
(Entity)
Please print using blue or black ink.
1
Deceased
IRA Owner
Information
Account number
Name of IRA owner (first, middle initial, last name)
Social Security number
2
Current
Beneficiary
Information
Fund name
Date of death (mo., day, year)
Name of beneficiary (Entity)
Tax identification number
Mailing address: Street
Apt.
City
State
ZIP code
Residence or legal address (if different than mailing address above): Street
City
Daytime telephone number
3
State
Extension
Apt.
ZIP code
Home telephone number
Associated
Person
Identity
Verification
Every associated person with the account must provide all the information requested. Important: If there
are more than two associated persons, provide the information, in the same format, on a separate sheet.
Name of Custodian/Trustee/Administrator/Executor/Other
(Required for
USA Patriot
Act.)
Social Security number
Date of birth (mo., day, year)
Account mailing address: Street
Apt.
City
State
ZIP code
Residence/Permanent address (We cannot accept a PO Box): Street
City
Daytime telephone number
State
Extension
Apt.
ZIP code
Home telephone number
E-mail address (optional)
(continued)
MF1024C
Ed. 4/2011
Page 4 of 9
3
Associated
Person
Identity
Verification
(continued)
Citizenship
U.S. person
Nonresident alien*
Resident alien country of residence
*Nonresident aliens must attach the applicable Internal Revenue Service (IRS) Form W-8(BEN, ECI, EXP,
IMY), which can be obtained at www.irs.gov.
Non U.S. citizens must provide valid government-issued proof of identity, if you have not provided your tax
identification number.
Identification (ID) type
Passport
Number
U.S. Visa
Number
U.S. Alien ID Card Number
Expiration date
Expiration date
Expiration date
Issuing country
Name of Custodian/Trustee/Administrator/Executor/Other
Date of birth (mo., day, year)
Social Security number
Account mailing address: Street
Apt.
City
State
ZIP code
Residence/Permanent address (We cannot accept a PO Box): Street
City
State
Daytime telephone number
Extension
Apt.
ZIP code
Home telephone number
E-mail address (optional)
Citizenship
U.S. person
Nonresident alien*
Resident alien country of residence
*Nonresident aliens must attach the applicable Internal Revenue Service (IRS) Form W-8(BEN, ECI, EXP,
IMY), which can be obtained at www.irs.gov.
Non U.S. citizens must provide valid government-issued proof of identity, if you have not provided your tax
identification number.
Identification (ID) type
Passport
Number
U.S. Visa
Number
U.S. Alien ID Card Number
MF1024C
Ed. 4/2011
Expiration date
Expiration date
Expiration date
Page 5 of 9
Issuing country
4
6
1.
(Choose
only one.)
5
Beneficiary
Options
2. Distribute the total amount of the portion in:
Decedent’s
Required
Minimum
Distribution
(RMD)
Information
Did the IRA owner satisfy his/her RMD requirement in the year of death?
New
Owner’s
RMD
Information
Complete only if option 1, in section 4 was chosen.
Transfer the portion of the account mentioned above to a new account for the benefit of the
designated party as stated in section 2.
a lump sum, or
to a new non-IRA account. (Any new fund account will require a completed non-IRA application.)
If existing, please provide account number.
Yes
No
If No or nothing is checked, a check representing the required minimum distribution amount will be sent
to you. If there are multiple beneficiaries, the required amount will be divided accordingly.
Calculate distribution based on life expectancy.
Frequency:
Monthly
Date of first distribution
month
Quarterly
day
Semiannually
Annually
year
I elect no payment at this time due to the death of the owner prior to age 70½. I understand that the
account must be distributed by December 31 of the fifth year following the owner’s death.
7
8
Please mail the distribution authorized in sections 4 and 5 to the following address:
Special
Mailing
Street
Instructions
for
City
State
ZIP code
Distributions
Bank
Account
Information
Apt.
If you would like the distribution authorized in section 4 to be sent electronically to your bank, complete this
section and attach a voided check or deposit slip. Note: The name of the beneficiary must appear on the
bank account specified.
Bank name
Bank account number
(continued)
MF1024C
Ed. 4/2011
Page 6 of 9
8
Bank
Account
Information
(continued)
ABA routing number (To ensure accuracy, verify with your bank.)
Type of account
Checking
Savings
Name of depositor on bank records (first, middle initial, last name)
Name of joint depositor on bank records (first, middle initial, last name)
Name on bank account
Street address
City, State ZIP
Check no. 1234
ID
O
DATE
Attach voided
check here.
PAY
TO THE
ORDER OF
FOR
V
123456789
9
DOLLARS
_________________________________
555555
ABA number (9 digits)
$
55555
1234
Bank account number
Tax
The taxable portion of the withdrawal that you receive will be subject to federal income tax withholding and
Withholding state income tax withholding, where applicable, unless you elect not to have withholding apply. The taxable
portion of your withdrawal will normally be subject to federal income tax withholding at a rate of 10 percent
Election
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.
Please note that if you are a U.S. citizen and your address of record is a non-U.S. address, we are required
to withhold income tax unless you provide us with a U.S. residential address. If applicable, please include
your U.S. residential address with this form.
By signing and dating this form and making no entries in this section, you can elect not to have any taxes
(federal or state) withheld, but you will still be liable for payment of any taxes due. Please check the
appropriate boxes if you want to have federal and/or state income tax withheld.
Withhold 10 percent federal income taxes on the taxable portion of my distribution. (If you want to have
more than 10 percent withheld, please indicate it in the box below.)
%
Percent
Dollar amount
(minimum 10 percent) or
$
,
(Amount cannot be less than 10 percent
of distribution.)
.
If you want to have state income taxes withheld from the taxable portion of your withdrawal, please
complete the appropriate box(es) below. Please be advised that if your resident state requires mandatory
withholding, we will withhold the default amount your state requires if you elect no withholding.
Withhold state income taxes on the taxable portion of my withdrawal based on the following criteria:
Percent
%
Specific dollar amount
or
$
,
.
Note: The percent or dollar amount cannot be less than the minimum required by your state of residence.
If the amount you selected is less, we will withhold the required amount.
MF1024C
Ed. 4/2011
Page 7 of 9
10
Authorization You must have your signature medallion signature guaranteed.
and Signature The medallion signature guarantee may be obtained from an authorized officer from a bank, broker, dealer,
Guranteed
securities exchange or association, clearing agency, savings association, or credit union that is participating
in one of the recognized medallion programs (STAMP, SEMP, or NYSE MSP). The medallion signature
guarantee must be appropriate for the dollar amount of the transaction. Prudential Mutual Fund Services LLC
reserves the right to reject transactions where the value of the transaction exceeds the value of the surety
coverage indicated on the medallion imprint.
X____________________________________________________
Authorized signature (e.g. trustee)
month
day
year
Place medallion signature guarantee here
Important: Please indicate the capacity in which you are acting by checking the appropriate box below. If
the correct box is not listed, please check “Other” and specify your capacity.
Aministrator/ Executor
Custodian
Trustee
Other, please specify
11
Tax
If this section is not completed, we may not be able to honor your election out of withholding.
Certification Complete (a) or (b) below:
and
(a) Under penalties of perjury, I certify that my correct taxpayer identification number is:
Signature
Beneficiary’s Social Security number
–
–
(We cannot
process this
form without
your
signature.)
Beneficiary’s date of birth
month
day
year
Complete the following, if applicable:
I am not subject to backup withholding for the reasons stated under “backup withholding” in the
instructions to the tax certification section.
(Check the box only if you are subject to backup withholding.)
I have been notified by the IRS that I am subject to backup withholding due to underreporting
of interest or dividends.
(b)
I am not a U.S. person (including resident alien). I am a citizen of
Attach the applicable IRS Form W-8(BEN, ECI, EXP, IMY).
By signing below, I certify and acknowledge that the information provided on this form is correct.
The IRS does not require your consent to any provision of this document
other than certification required to avoid backup withholding.
X____________________________________________________
Authorized signature (e.g. trustee)
MF1024C
Ed. 4/2011
Page 8 of 9
month
day
year
12 Financial
Professional(s)
Identification
and
Signature(s)
(if applicable)
Your new IRA or inherited IRA will be automatically set up with the same financial professional as the decedent's
existing IRA unless the section below is completed. If you would like to make a change, please have your new
financial professional complete the following section.
Pruco Securities registered representatives must complete the USA Patriot Act Customer Identity Verification form
and submit it with this form.
1. Financial professional (first name, MI, last name) (Please print.)
Financial professional’s signature X
Broker/dealer name (Please print.)
Broker/dealer number
Financial prof.#/Contract #
Branch office #/Agency code
Percent
Office phone number
Alternate phone number
2. Financial professional (first name, MI, last name) (Please print.)
Financial professional’s signature X
Broker/dealer name (Please print.)
Broker/dealer number
Branch office #/Agency code
Percent
MF1024C
Financial prof.#/Contract #
Office phone number
Alternate phone number
Ed. 4/2011
Page 9 of 9
