Request for Collateral Assignment/Discharge of Assignment

Request for Collateral Assignment / Discharge of Assignment

Use this form to make a collateral assignment (“assignment”) or to discharge the assignment of a policy.

Instructions

1. Read page 1 of this form carefully. Please keep this page for your reference.

2. Complete pages 2 through 4, as appropriate.

3. Review the accuracy of any information that we may have filled in. Initial any changes, corrections, or deletions that are made.

Except in section 7, I, you, and your refer to the policyowner(s). We, us, and our refer to the Prudential company that issued the policy. Assignee refers to the collateral assignee.

To Make a Collateral Assignment

More than one policy can be collaterally assigned with this form as long as each policy insures the same person(s), has the same owner(s), and the same assignment is being requested for each policy. Please follow these steps:

1. Complete sections 1 and 2.

2. Provide the full name and complete address of the assignee(s) in section 3.

3. Complete section 4 if there are more than two joint assignees. This section should contain the full name and complete address of each additional assignee.

4. The beneficiary(ies) must sign section 6 if the Death Benefit is payable to other than the insured’s estate and if the policy was issued before September 1935, or has a policy number preceded by “M” and which is numbered below M7 000 000.

5. Review the signature requirements in section 5, then be sure to include your signature(s) and the date(s) in section 6. If the policy currently contains a limitation of rights, which limits the right to assign, the person or entity in whose favor the rights have been limited must sign this section.

6. Return pages 2 through 4 to Prudential, and keep page 1 for your information. Please do not send us the policy. It is not required.

We will acknowledge the assignment and return the acknowledged form to the assignee unless otherwise requested. Once we have acknowledged and filed an assignment, it will remain in effect until we receive and file written notice of discharge.

Important Tax Information

If your policy has been determined to be a modified endowment contract and it is collaterally assigned, we must report all cumulative earnings in the policy as income to you on an Internal Revenue Service Form 1099-R. You may wish to consult with your tax adviser before making the collateral assignment.

To Discharge an Assignment

More than one assignment can be discharged with this form as long as each policy assigned insures the same person(s), has the same owner(s), and the same assignment is being discharged for each policy. Please follow these steps:

1. Complete sections 1 and 2.

2. Review the signature requirements in section 5, then be sure to have the assignee(s) sign and date section 7.

3. Return pages 2 through 4 to Prudential. Please do not send us the policy. It is not required.

1. About Your Policy

Policy number (Eight or nine characters. If eight, leave last space empty.)

Name of insured (first, middle initial, last name)

Name of joint insured, if any (first, middle initial, last name)

2. About the Policyowner(s)

Name of policyowner (first, middle initial, last name). Enter “same” if same as insured.

Name of joint owner, if any (first, middle initial, last name)

3. Request for a Collateral Assignment

I assign to the collateral assignee(s) named in this section, a collateral interest in the policy(ies) indicated in section 1, subject to the provisions of the policy and to any indebtedness that may exist.

List below any other rights to be exercised by the owner without the consent of the assignee.

List below any other rights to be exercised by the assignee without the consent of the owner.

4. Additional Information

Use this section if the assignment is for more than two joint assignees. For each additional joint assignee, please provide a full name and address.

5. Signature Requirements

Please review these signature requirements before signing in section 6 for a collateral assignment or in section 7 for a Discharge of Assignment.

• For corporations, an authorized officer must sign. Be sure to include the title of the officer.

• If president – no additional requirements

• If vice president – for policies over $1,000,000, provide a Corporate Secretary’s statement reflecting the vice president’s authority to sign

• If any other officer – provide a corporate resolution

• For partnerships with at least two general partners, two authorized general partners must sign with the title “general partner” after each name (if only one, use “sole general partner”) and include the name of the partnership.

• For sole proprietorships, submit the signature of the owner, followed by “doing business as (company name), a sole proprietorship.”

• For trusts, each trustee must sign unless the trust itself or state law provides otherwise. Trustee must include trustee designation.

• A holder of power of attorney must provide a copy of the power of attorney and include, following his or her signature, the words “Attorney-in-fact for (owner’s name).”

• For a policy containing a limitation of rights, the person or entity in whose favor the rights have been limited must also sign.

6. Assignment Signature(s) (All owners must sign.)

By signing this form, I certify that I am authorized to sign this form, authorize the collateral assignment requested on this form, and certify the ownership status described in the form instructions.

7. Discharge of Assignment Signature(s)

By signing this form, I authorize the release and discharge of any and all assignments indicated above.

Acknowledgment (For Home Office use only.)

Assignment recorded and filed by us.

Discharge recorded and filed by us.

For Prudential Use Only