IRA, Roth IRA & SEP IRA Application

Transcription

1 Prudential Mutual Fund Services LLC (PMFS), a Prudential Financial company Instructions IRA, Roth IRA & SEP IRA Application For assistance: Financial professionals: (888) Clients: (800) Please print clearly, preferably in capital letters and black ink. Return completed application to Prudential Mutual Fund Services LLC. See page 9 for complete mailing instructions. The annual maintenance fee is $15 per fund, with a $25 maximum for two or more funds. 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. 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) 1 If this information is not provided, we will be unable to open the account. If we are unable to verify your identity, Prudential Financial reserves the right to close your account or take other steps we deem reasonable. Account Ownership All information is required. If a minor IRA account is being setup, then please provide the information of the custodian/guardian, in the same format, on a separate sheet. First name MI Last name Social Security number Date of birth Account mailing address City State ZIP code 4-digit ext. Residential/Permanent address (Complete if different from above or PO Box was provided for account mailing address.) City State ZIP code 4-digit ext. Home telephone number Daytime telephone number Extension address (optional) Citizenship U.S. Citizen Resident alien Nonresident 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 Also, nonresident aliens must cross out item 3 in section 12. Marital Status Married Single Widowed Divorced Number of Dependents MF1011 Ed. 3/2011 Page 1 of 9

2 2 Beneficiary Designations Those you designate as your primary beneficiaries will be the first to inherit your mutual fund assets upon your death. Secondary beneficiaries will receive the balance of your mutual fund assets only after the primary beneficiary. Indicate the percentages for each beneficiary. The primary and secondary beneficiary totals must each equal 100%. Spousal Consent - If you are a married person and have not designated your spouse as your sole primary beneficiary, your spouse must sign section 12. A. Primary Beneficiaries (check all that apply) My Spouse (Select one only. Do not check both boxes.) } To the person I am married to at the time of my death OR My spouse by name % Name (first, MI, last name) Date of birth (mm/dd/yyyy) My Descendants If you want your assets divided into unequal amounts to your descendants, then list the names and percentages of each person in the Individual section. To my descendants who survive me, per stirpes % With per stirpes, your assets will be divided equally among your children. If a child is deceased, the entire portion due to that child will be divided equally among his or her children (if any). Note: Step children, foster children, etc are not included. Equally to my grandchildren who survive me % Individuals If the Per Stirpes designation is checked and the named beneficiary does not survive the account owner, but leaves surviving descendants, then any share otherwise payable to such beneficiary shall instead be paid to such beneficiary s surviving descendants, by right of representation. Note: If you need more space to list additional beneficiaries, provide all the information in the same format on a separate sheet with the date and your signature. Name (first, MI, last name) Date of birth (mm/dd/yyyy) Relationship to owner Add a Per Stirpes designation (optional designation) % Name (first, MI, last name) Relationship to owner Name (first, MI, last name) Relationship to owner Date of birth (mm/dd/yyyy) Add a Per Stirpes designation (optional designation) Date of birth (mm/dd/yyyy) Add a Per Stirpes designation (optional designation) % % Trusts & Other Designations Trust, Entity or Charitable Organization Name Date of Trust (mm/dd/yyyy) % My Estate... % If the total does not equal 100%, Prudential will allocate equal percentages totaling 100% > % MF1011 Ed. 3/2011 Page 2 of 9

3 2 Beneficiary Designations (continued) B. Secondary Beneficiaries (check all that apply) My Spouse (Select one only. Do not check both boxes.) } To the person I am married to at the time of my death OR My spouse by name % Name (first, MI, last name) Date of birth (mm/dd/yyyy) My Descendants If you want your assets divided into unequal amounts to your descendants, then list the names and percentages of each person in the Individual section. To my descendants who survive me, per stirpes % With per stirpes, your assets will be divided equally among your children. If a child is deceased, the entire portion due to that child will be divided equally among his or her children (if any). Note: Step children, foster children, etc are not included. Equally to my grandchildren who survive me % Individuals If the Per Stirpes designation is checked and the named beneficiary does not survive the account owner, but leaves surviving descendants, then any share otherwise payable to such beneficiary shall instead be paid to such beneficiary s surviving descendants, by right of representation. Note: If you need more space to list additional beneficiaries, provide all the information in the same format on a separate sheet with the date and your signature. Name (first, MI, last name) Date of birth (mm/dd/yyyy) Relationship to owner Add a Per Stirpes designation (optional designation) % Name (first, MI, last name) Relationship to owner Name (first, MI, last name) Relationship to owner Date of birth (mm/dd/yyyy) Add a Per Stirpes designation (optional designation) Date of birth (mm/dd/yyyy) Add a Per Stirpes designation (optional designation) % % Trusts & Other Designations Trust, Entity or Charitable Organization Name Date of Trust (mm/dd/yyyy) % My Estate... % If the total does not equal 100%, Prudential will allocate equal percentages totaling 100% > C. Minor Beneficiaries (optional) If any beneficiary named in this form is a minor, I hereby request that proceeds be paid to as custodian under the (name of state) UTMA (to the extent permitted by named state). Important: The date of birth of the named minor is required in Section 2 (Individuals) for this designation to apply % MF1011 Ed. 3/2011 Page 3 of 9

4 3 Account Type & Contribution Information A. Account Type (Choose only one.) Traditional IRA Rollover IRA Roth IRA*(Establishment date) SEP IRA**(Employer name) *The establishment date is the earliest date you either opened a Roth IRA or originally converted from a traditional IRA to a Roth IRA. This information is requested by the IRS and is needed to determine compliance with the taxable five-year holding period requirement. **For SEP IRAs, the tax year for employer contributions is for your informational purposes only; all employer contributions are reported in the year received by Prudential Mutual Fund Services LLC (PMFS). B. Inherited IRA Decedent s First name MI Last name Decedent s Date of death Note: Please complete and attach the Request for IRA Beneficiary Distribution (Spouse and Non-Spouse) form (MF1024A) or the Request for IRA Beneficiary Distribution (Entity) form (MF1024C) to establish required minimum distributions (RMD) from your new inherited IRA. C. Contribution/Purchase Instructions Contributions (For SEP IRAs, input employee contributions as a Contribution.) Contribution for tax year 2 0 Regular $ Catch-up $ Contribution for tax year 2 0 Regular $ Catch-up $ Employer contribution for tax year 2 0 Amount $ (SEP IRA only) Employer contribution for tax year 2 0 Amount $ (SEP IRA only) Rollover Purchase. Within 60 days of your receipt either from another like IRA (e.g. Roth IRA to Roth IRA or Traditional IRA to Traditional IRA) or an eligible rollover distribution from a retirement plan to a Traditional IRA, Rollover IRA or Roth IRA. Rollover check amount $ Direct Rollover from an employer-sponsored retirement plan. Complete the Transfer/Direct Rollover/Conversion Authorization form (MF1012). Estimated amount $ Direct Rollover from a Roth 401(k) plan or Roth 403(b) plan. Complete the Transfer/Direct Rollover/Conversion Authorization form (MF1012). Transfer of an existing IRA, Roth IRA, SEP IRA, or SARSEP account from another custodian. Complete the Transfer/Direct Rollover/Conversion Authorization form (MF1012). Conversion from an existing Traditional IRA, SEP IRA, or SARSEP IRA account from another custodian into a Roth IRA. Complete the Transfer/Direct Rollover/Conversion Authorization form (MF1012). Estimated amount $ Estimated amount $ Estimated amount $ Please make check payable to Prudential Mutual Fund Services. MF1011 Ed. 3/2011 Page 4 of 9

5 4 Mutual Fund Selection & Allocation Please provide your investment selections by checking the box next to the fund number and indicate allocations as either a percentage (%) or dollar amount ($). If a fund offers a share class not listed, then write the fund number or share class in the Other column next to the fund name. Refer to the fund s prospectus for fund minimum and eligibility requirements. EQUITY FUNDS OTHER FUNDS Asset Allocation Large-Cap Stock Small / Mid-Cap Stock Specialty International Stock FIXED Taxable INCOME Bond FUNDS Global Bond Municipal Bond Money Market Asset Allocation Fund Share Class Fund Name Class A Class B Class C Other % $ Prudential Asset Allocation Fund % $ Prudential Conservative Allocation Fund % $ Prudential Growth Allocation Fund % $ Prudential Moderate Allocation Fund % $ Prudential Large-Cap Core Equity Fund % $ Prudential Stock Index Fund % $ Prudential Strategic Value Fund % $ Prudential Jennison 20/20 Focus Fund % $ Prudential Jennison Blend Fund % $ Prudential Jennison Conservative Growth Fund % $ Prudential Jennison Growth Fund % $ Prudential Jennison Select Growth Fund % $ Prudential Jennison Value Fund % $ Prudential Mid-Cap Value Fund % $ Prudential Small-Cap Value Fund % $ Prudential Jennison Mid-Cap Growth Fund % $ Prudential Jennison Small Company Fund % $ Prudential Global Real Estate Fund % $ Prudential International Real Estate Fund % $ Prudential Jennison Equity Income Fund % $ Prudential Jennison Equity Opportunity Fund % $ Prudential Financial Services Fund % $ Prudential Jennison Health Sciences Fund % $ Prudential Jennison Market Neutral Fund % $ Prudential Jennison Natural Resources Fund % $ Prudential Jennison Utility Fund % $ Prudential Real Assets Fund % $ Prudential US Real Estate Fund % $ Prudential International Equity Fund % $ Prudential International Value Fund % $ Prudential Absolute Return Bond % $ Prudential Floating Rate Income Fund % $ Prudential Government Income Fund % $ Prudential High Yield Fund % $ Prudential Short-Term Corporate Bond Fund % $ Prudential Total Return Bond Fund % $ Prudential Global Total Return Fund % $ Prudential Emerge Mrkt Dbt Local Currency Fund % $ Prudential California Muni Income Fund % $ Prudential Muni High Income Fund % $ Prudential National Muni Fund % $ Total: (100% or $) Initial Investment Prudential MoneyMart Assets % $ Target Conservative Allocation Fund % $ Target Growth Allocation Fund % $ Target Moderate Allocation Fund % $ Note: The total must equal 100% or the total dollar amount provided in section 3. MF1011 Ed. 3/2011 Page 5 of 9

6 5 Letter of Intent & Rights of Accumulation Letter of Intent (LOI): Check here if establishing, complete the Letter of Intent form (MF230 PMFS), and include with this application. Financial professionals can request a copy by calling (888) Rights of Accumulation: Check here and list account numbers below if you qualify for sales discounts on Class A shares. Please refer to the fund's prospectus and Statement of Additional Information to learn more about accounts that may be eligible. Indicate eligible accounts below. Note: All eligible funds may be aggregated for purposes of sales discounts on Class A shares. If such funds are not held directly at PMFS, you should inform your sales professional in order to take advantage of these discounts. Account Number Account Owner Name (first name, MI, last name) Relationship to You 6 Distribution Options All dividends and capital gains will be reinvested if you do not make an election. Dividends Reinvest in shares Pay in cash* Send by ACH to the bank specified in section 9. Capital Gains Reinvest in shares Pay in cash* Send by ACH to the bank specified in section 9. *If the dividends and capital gains are to be distributed in cash or sent by ACH, please complete, sign and return IRS Form W-4P with this application. 7 Telephone/Online Exchange and Redemption Option Your account will automatically be coded with the Telephone/Online Redemption and the Telephone/Online Exchange Privileges, unless you check the No box below. I do not want telephone exchange and redemption privileges. Unless otherwise indicated above, you authorize the Fund s distributor, Prudential Investment Management Services LLC (PIMS), to accept telephone exchange and redemption instructions from any person identifying himself/herself as the owner of the account or as the owner s dealer representative conveying instructions of the owner. PIMS and/or the Fund s transfer agent, Prudential Mutual Fund Services LLC (PMFS), will employ reasonable procedures to confirm that such telephone instructions are genuine. Neither the Funds, PIMS nor PMFS shall be liable for any losses due to unauthorized or fraudulent instructions provided that such procedures are followed. Telephone exchanges and redemptions are subject to the procedures and conditions set forth in each Fund s prospectus. MF1011 Ed. 3/2011 Page 6 of 9

7 8 Purchase Options (Check all that apply.) A. ACH Purchase Option: Check if you want the capability to make wire purchases, online or by telephone, upon demand, by having the purchase amount debited from your bank account. B. Automatic Investment Plan (AIP): Set up recurring purchases into a fund and have the purchase amount debited from your bank account. Note: All contributions will be processed as current year contributions and the total contributions may not exceed the maximum allowed per tax year. Frequency (The minimum investment amount is $50 per fund.) : Weekly on (enter day of week e.g. Monday) Monthly on the (enter a day of the month e.g. 15th) Start date* *If a specific day of the month is not listed above, debits will be made on or about the 15th of the month. Share class $ into the Fund A B C $ into the Fund A B C $ into the Fund A B C $ into the Fund A B C $ into the Fund A B C $ into the Fund A B C $ Total amount (to be debited from bank/credit union account as specified in section 9) Other 9 Bank of Record* Bank/Credit union name Bank telephone number Bank routing number Bank account number *To ensure accuracy, verify with your bank or credit union. Name of depositor on bank records (first, middle initial, last name) Bank type: Checking Savings Name of joint depositor on bank records (first, middle initial, last name) Attach voided check here. Name on bank account Check no Street address City, State ZIP DATE PAY TO THE ORDER OF $ FOR Routing number (9 digits) VOID Bank account number DOLLARS MF1011 Ed. 3/2011 Page 7 of 9

8 10 e-delivery and Mailing Preferences* Why wait for the mail if you can get your account statements, confirmations, prospectuses, and fund reports faster by signing up for e-delivery? By registering for this convenient and environmentally-friendly service, you will receive your Prudential mutual fund documents online instead of in the mail. As new documents become available, you will receive an informing you of the new documents and instructions on how to view them online. You may change your address or cancel participation at any time by updating your mailing preferences. Note: Certain entity and institutional accounts are not eligible for e-delivery. Account Statements: e-delivery U.S. mail e-delivery and mail year-end statement Confirmations: e-delivery U.S. mail Prospectus, Fund Reports, and Proxy Mailings: e-delivery U.S. mail *All documents will be sent to you by U.S. Mail if you do not make a selection. By enrolling for e-delivery, you consent to receive online versions rather than paper copies of materials for your mutual fund accounts at Prudential Mutual Fund Services LLC (PMFS). Once your account is established, PMFS will contact you by with instructions to complete the online enrollment process and to log in to our website. We will only use your address to provide you with the material you requested or to send important news about your account. address for e-delivery 11 Financial Professional(s) Identification and Signature(s) (if applicable) Broker/dealer name (Please print.) Broker/dealer number Branch number Representative number* *If more than one rep, use your joint rep number. 1. Financial professional (first name, MI, last name) (Please print.) Financial professional s signature X Branch telephone number Alternate telephone number 2. Financial professional* (first name, MI, last name) (Please print.) Financial professional s signature X Branch telephone number Alternate telephone number MF1011 Ed. 3/2011 Page 8 of 9

9 12 Spousal Consent Authorization Special laws apply to the designation of an IRA beneficiary by a married person residing in a "community property" state. If you are married and reside in a community property state and have not designated your spouse as your sole primary beneficiary in section 2, your spouse must sign this section. Your spouse's signature represents consent to the beneficiary designation. First name MI Last name Sign here Signature of spouse X (of IRA owner) Date 13 Signature and Tax Certification The undersigned warrants that I have full authority and I am of legal age to purchase shares pursuant to this application. Further, I acknowledge receipt of the prospectus(es) for the mutual fund(s) which I have selected, and agree to its/their terms. I acknowledge receipt of the applicable Individual Retirement Custodial Account Agreement and Disclosure Statement and I understand that there may be fees associated with this account. I consent to the householded delivery of any mutual fund prospectuses, shareholder reports, or proxy statements. This means Prudential Mutual Fund Services LLC (PMFS) will deliver a single copy of these documents to shareholders who share an address, even if the accounts are registered in different names. My participation in this program will continue indefinitely unless I contact PMFS. According to Federal law and/or state regulations, your account(s) may be subject to escheatment to your state of residency. Escheatment may be based on account inactivity and/or mail being returned by the post office (RPO). Check with your state Controller s office for additional guidance. Under penalties of perjury, I certify that: (1) The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), (2) I am not subject to backup withholding because: a) I am exempt from backup withholding; b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or c) the IRS has notified me that I am no longer subject to backup withholding, and (3) I am a U.S. person (including a U.S. resident alien). You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because of underreporting interest or dividends on your tax return. You must cross out item 3 if you are a not a U.S. person (including a U.S. resident alien). 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. This verification process will take place as we open your account. Once verification is completed, Prudential Financial will be able to fully service and maintain the account. Account Restriction: Check here if you would like PMFS to establish a restricted account from which funds shall be disbursed only upon receipt of a valid court order or other document(s), as appropriate. A copy of the restriction (court order or otherwise), signed and dated on has been provided with this mutual fund application. The restriction shall continue until PMFS receives a valid court order or other written instruction as directed by PMFS, expressly authorizing the removal of the restriction. The IRS does not require your consent to any provision of this document other than the certification required to avoid backup withholding. Sign here Owner s signature X Date Mailing Instructions for Mutual Fund Account Application Standard Prudential Mutual Fund Services LLC Overnight mail to: PO Box 9658 Providence, RI mail to: Prudential Mutual Fund Services LLC 4400 Computer Drive Westborough, MA MF1011 Ed. 3/2011 Page 9 of 9

10 Transfer/Direct Rollover/ Conversion Authorization 1 Prudential Mutual Fund Services LLC (PMFS), a Prudential Financial company Instructions Submit a separate transfer form for each Resigning Custodian and each unique account type. Account Owner Information First name MI Last name For assistance: Clients: (800) Pruco representatives: (800) Financial professionals: (888) Social Security number PMFS account number (Required for existing accounts only.) 2 Account(s) to be Transferred to PMFS (Please attach copies of your most recent account statements.) Complete all sections for your request to be processed. Note: Prudential Mutual Fund Services LLC cannot accept stock certificates. A. Account types being transferred to PMFS Traditional IRA Roth IRA SEP-IRA 403(b) Plan Governmental 457 Plan Roth 401(k) Plan Roth 403(b) Plan SIMPLE IRA Employer-Sponsored 401(a) Retirement Plan (i.e., 401(k), pension or profit sharing plan, or defined benefit plan) B. Account number(s) to be transferred C. Resigning Custodian information Name of institution/employer-sponsored retirement plan from which the accounts in section B above will be transferred Attention Mailing address City State ZIP code 4-digit ext. Contact telephone number Extension Name of contact person or department 3 4 Transfer Instructions All liquidations are done immediately unless special instructions are provided below. Check with your sending institution about financial penalties, suspensions, signature guarantees, or other restrictions that could affect the transfer of your account to PMFS. A. Liquidate All $ (estimated value) Partial % or $ B. Special instructions for CDs and certain annuity contracts Transfer immediately. I am aware of and acknowledge any penalty I may incur from an early withdrawal. Transfer-in-Kind Instructions Transfer at maturity (month, day, year): (Please submit 4 weeks prior to maturity date.) Complete this section only if you have existing Prudential mutual funds and want to change your current Trustee/Custodian. Prudential shares will not be sold. Transfer my funds in kind immediately. Important: Section 3 must be completed for any general securities to be liquidated. Otherwise, only Prudential positions will be transferred. MF1012 Ed. 3/2011 Page 1 of 3

11 PMFS Account Type The transferred proceeds will be invested into the following account type. Traditional IRA, Rollover IRA, or SEP IRA Roth IRA or Roth Conversion IRA Establishment date* 403(b) Plan You must have an existing account at PMFS. New accounts will not be accepted. *The date you originally contributed to a Roth IRA or converted from a traditional IRA to a Roth IRA. This information is required by the IRS for compliance with the 5 tax-year holding period requirement. Mutual Fund Selection and Allocation I am opening a new account and have attached a completed application. Allocation instructions are included in section 4 of my new account application. For this transfer request, invest the amount received into my existing account(s) (indicated in section 1) in the funds and allocations listed below. Please provide investment fund selections and indicate allocations. Refer to the fund's prospectus for the fund minimum and eligibility requirements. Note: All allocations by percentage must total 100%. Share class Fund name Fund number Percent Amount A B C Other % or $ % or $ % or $ % or $ % or $ % or $ Total % or $ Fund Holding Years. Indicate the number of years you intend to hold your mutual fund Withholding Election and Roth Conversion Disclosure Federal tax law requires that income tax be withheld at a rate of 10% from the total amount of your IRA distribution/conversion unless you elect not to have tax withheld. Depending on your state of residence, state tax withholding may also apply. If you do not want taxes withheld, proceed to the next section. If you would like to have taxes withheld, please check the box below: I would like federal and applicable state income taxes withheld from my IRA distribution being converted to a Roth IRA. I understand that, as a result, the portion of my IRA distribution that is withheld as income taxes will not be converted to my Roth IRA and may result in adverse tax consequences. (Please consult with your tax adviser.) If you would like more than 10% withheld, please indicate below: Federal taxes Mailing Instructions for Resigning Custodian State taxes* (Percentage or Dollars) Percentage: % (minimum 10% distribution), or Percentage: %, or Dollar amount $ (Amount cannot be less than 10% of distribution.) Dollar amount $ *Percentage/dollar amount cannot be less than the minimum required for your state. Checks should be made payable to PMFS for the benefit of (account owner). Checks should be sent to: Standard Prudential Mutual Fund Services LLC mail to: PO Box 9658 Providence, RI Overnight mail to: Prudential Mutual Fund Services LLC 4400 Computer Drive Westborough, MA If you have any questions, please call PMFS at (800) , Monday through Friday between 8 a.m. to 6 p.m. Eastern time. MF1012 Ed. 3/2011 Page 2 of 3

12 9 Authorization For Traditional IRAs, Roth IRAs, SEP-IRAs, and 403(b) accounts. It is my intention to effect a transfer, without inclusion of the amount to be transferred in my gross income. You are directed to transfer all or a portion of the redemption value of the account as identified in section 2 to an account established for me with Prudential Trust Company (PTC) as custodian. Accordingly, you are hereby directed to request on my behalf the transfer of my interest in the account referenced in section 2 for subsequent investment in Prudential Mutual Funds for investment in the custodial account(s) maintained for me. I hereby agree to the terms and conditions set forth in this Transfer/Direct Rollover/Conversion Authorization. For direct rollover. This authorizes the employer-sponsored retirement plan designated in section 2 to distribute my eligible rollover distribution directly from my retirement plan to PTC in accordance with the instructions in section 3. I understand that the conversion of a traditional IRA to a Roth IRA will result in a taxable event which will be reported to the IRS. If the account owner has attained the age of 70½ or older in the year of this transfer request, the required minimum distribution must be removed prior to the transfer being made. I understand that the Resigning Custodian may charge a closeout fee for IRA accounts. The default election is for the Resigning Custodian to redeem shares to cover charges. I authorize the Resigning Custodian to redeem shares to cover those charges. I will arrange to cover those charges by other means. Important: If elected, any fees must be paid to the resigning custodian, prior to submitting this form, or they may deny the request. Sign here Owner s signature X Date Signature Guarantee (If applicable, may be required by Resigning Custodian.) Prudential Trust Company's Acceptance (To be completed by PMFS.) Prudential Mutual Fund Services LLC, as agent for the Prudential Trust Company (PTC) which is custodian of the traditional IRA, Roth IRA, SEP IRA or 403(b) plan, hereby confirms its acceptance of the above mentioned transfer or rollover. Authorized signature of Prudential Mutual Fund Services LLC (as agent for PTC) X Financial Professional Identification and Signature (if applicable) Financial professional s name (first name, MI, last name) (Please print.) Financial professional s signature X Broker/Dealer s name (Please print.) Broker/Dealer number Branch/Agency number Rep./Contract number Branch telephone number Alternate telephone number MF1012 Ed. 3/2011 Page 3 of 3

13 1 Prudential Mutual Fund Services LLC (PMFS), a Prudential Financial company Instructions Authorization to Convert from a Traditional IRA to a Roth IRA For assistance: Clients: (800) Pruco representatives: (800) Financial professionals: (888) Use this form to request a distribution from your current PMFS traditional IRA and have the proceeds invested in a new or existing PMFS Roth IRA. Note: Conversion from a traditional IRA to a Roth IRA is a reportable, taxable event and may not be suitable for everyone. You should consult with your tax adviser to review the consequences of this conversion. Please follow these steps: Read the statement in section 6 and sign where indicated. Make sure you have received and read a copy of the Roth IRA Custodial Agreement and Disclosure Statement included with the IRA and Roth IRA Application. If you would like to add or to change the beneficiary designation on your Individual Retirement Account (IRA), please complete the MF 1001 Beneficiary Designation form. Mutual Fund Account Ownership Information Name (first, MI, last name) Mr. Ms. Mrs. Mailing address City State ZIP code 4-digit ext Social Security number Date of birth Fund name (Specify portfolio and class of shares, if applicable.) Fund number Account number Daytime telephone number Distribution Direction Prudential Mutual Fund Services LLC is hereby directed to complete this distribution from a traditional IRA and apply the proceeds to a Roth IRA dated: Note: The establishment date is the earliest date you either opened a Roth IRA or originally converted from a traditional IRA to a Roth IRA. This information is requested by the IRS for compliance with the 5-year IRS holding period requirement. Please be aware that if you are requesting a conversion into an existing Roth IRA, a separate 5-year holding period applies to each conversion. PMFS will only track the holding period for the initial transaction that established the Roth IRA. It is your responsibility to track the holding period for each subsequent conversion. Method of Distribution Please distribute the following amount from my traditional IRA (check one): Full distribution (100%) Partial distribution in the amount of $,. in cash Partial distribution for shares Fund Allocation I want the distribution indicated above to be invested into the following fund: Same fund as indicated in section 1 above New fund Existing account: Fund number Account number MF1028 Ed. 3/2011 Page 1 of 2

14 5 Withholding Election and Roth Conversion Disclosure Federal tax law requires that income tax be withheld at a rate of 10% from the total amount of your IRA distribution/conversion unless you elect not to have tax withheld. Depending on your state of residence, state tax withholding may also apply. If you do not want taxes withheld, sign the election form below. By signing this form, you elect not to have taxes withheld. If you would like to have taxes withheld, please check the box below: I would like federal and applicable state income taxes withheld from my IRA distribution being converted to a Roth IRA. I understand that, as a result, the portion of my IRA distribution that is withheld as income taxes will not be converted to my Roth IRA and may result in adverse tax consequences. (Please consult with your tax adviser.) If you would like more than 10% withheld, please indicate below: Federal taxes Percentage: Dollar amount $ % (minimum 10% distribution), or,. (Amount cannot be less than 10% of distribution.) State taxes* Percentage: Dollar amount $ %, or,. *Percentage/dollar amount cannot be less than the minimum required for your state. 6 Signature By signing below, I certify that: The information provided on this form regarding my status with respect to the account involved and all other aspects is correct. I understand that converting from a traditional IRA to a Roth IRA is a taxable event which will be reported to the IRS and I will be responsible for paying any income tax which might result from this conversion. I have received and read a copy of the Roth Individual Retirement Custodial Account Agreement, Disclosure Statement and applicable fund prospectuses. Sign here X Date Mailing Instructions for Mutual Fund Account Application Standard Prudential Mutual Fund Services LLC mail to: PO Box 9658 Providence, RI Overnight mail to: Prudential Mutual Fund Services LLC 4400 Computer Drive Westborough, MA MF1028 Ed. 3/2011 Page 2 of 2

15 Privacy Notice This notice is being provided on behalf of the companies listed in this Notice. It describes how information about you is handled and the steps we take to protect your privacy. We call this information customer data or just data. If you have other Prudential products or relationships, you may receive a separate privacy notice describing the practices that apply to those products or relationships. If your relationship with us ends, we will continue to handle data about you the same way we handle customer data. Protecting Customer Data We maintain physical, electronic, and procedural safeguards to protect customer data. The only persons who are authorized to have access to it are those who need access to do their jobs. We require them to keep the data secure and confidential. Information We Collect We collect data you give us and data about the products and relationships you have with us, so that we can serve you, including offering products and services to you. It includes, for example: your name and address, income and Social Security number. We also collect data others give us about you, for example: medical information for insurance applications, consumer reports from consumer reporting agencies, and participant information from organizations that purchase products or services from us for the benefit of their members or employees, for example, group life insurance. Sharing Data We may share data with affiliated companies and with other companies so that they can perform services for us or on our behalf. We may, for example, disclose data to other companies for customer service or administrative purposes. We may disclose limited information such as: your name, address, and the types of products you own to service providers so they can provide marketing services to us. We may also disclose data as permitted or required by law, for example: to law enforcement officials, in response to subpoenas, to regulators, or to prevent fraud. We do not disclose data to Prudential affiliates or other companies to allow them to market their products or services to you. We may tell you about a product or service that a Prudential company or other companies offer. If you respond, that company will know that you were in the group selected to receive the information. Annual Notices We will send notices at least once a year, as federal and state laws require. We reserve the right to modify this policy at any time. If you have questions about Prudential s Privacy Notice please call us. The toll-free number is (800) Prudential, Prudential Financial and the Rock logo are registered service marks of The Prudential Insurance Company of America, Newark, NJ and its affiliates. The Prudential Insurance Company of America, 751 Broad Street, Newark, NJ Your Financial Security, Your Satisfaction & Your Privacy Privacy 0019 Ed. 1/2011 MUTU-D4413

16 Many Prudential Financial companies are required to send privacy notices to their customers. This notice is being provided to customers of the Prudential Financial companies listed below: Insurance Companies and Separate Accounts Prudential Insurance Company of America, The Prudential Annuities Life Assurance Corporation Pruco Life Insurance Company Pruco Life Insurance Company of New Jersey Prudential Retirement Insurance and Annuity Company (PRIAC) PRIAC Variable Contract Account A CG Variable Annuity Account I & II (Connecticut General) Pruco Insurance Company of Iowa All separate accounts that include the following names: Prudential, Pruco, and PRIAC Insurance Agencies Prudential Insurance Agency, LLC Broker-Dealers and Registered Investment Advisers AST Investment Services, Inc. Prudential Annuities Distributors, Inc. Global Portfolio Strategies, Inc. Prudential Bache Securities, LLC Pruco Securities, LLC Prudential Investment Management, Inc. Prudential Investment Management Services LLC Prudential Investments LLC Bank and Trust Companies Prudential Bank & Trust, FSB Prudential Trust Company Investment Companies and Other Investment Vehicles Asia Pacific Fund, Inc., The Greater China Fund Inc., The Prudential Investments Mutual Funds Prudential Capital Partners, L.P. Target Portfolio Trust, The PB Financial Services, Inc. Advanced Series Trust The Prudential Series Fund All funds that include the Prudential name Futures Commission Merchant Prudential Bache Commodities, LLC MUTU-D4413

17 Roth Individual Retirement Custodial Account Agreement This Agreement governs the Participant's Prudential Roth Individual Retirement Custodial Account ("IRA"), and is made between the Depositor and the Custodian to establish a Roth Individual Retirement Custodial Account under section 408A of the Internal Revenue Code (the "Code") for the exclusive benefit of the Depositor and his or her beneficiaries. Actions by or for the Custodian shall also be deemed to include actions by or for the Custodian's designee (herein Prudential Mutual Fund Services, LLC, also referred to as PMFS). ARTICLE I DEFINITIONS 1. Application The application by which this Agreement, as it may be amended from time to time, is accepted by the Participant. The signed Application, and the statements contained therein, are an integral part of this Agreement. 2. Beneficiary The person or persons designated as such in the Application or as indicated in the latest subsequent written beneficiary designation received by the Custodian from the Participant. 3. Code The Internal Revenue Code of 1986, as amended from time to time. 4. Custodial Account The Individual Retirement Custodial Account established under this Agreement. The account is established for the exclusive benefit of the individual or his or her beneficiaries. The interest of an individual in the balance in his or her account is nonforfeitable at all times. 5. Depositor Individual who makes contributions to this or other Individual Retirement Accounts on his or her own behalf. 6. Disability The inability of an individual to engage in any substantial gainful activity by reason of any medically determined physical or mental impairment, which can be expected to result in death or to be of long, continued, and indefinite duration. An individual shall not be considered to be permanently and totally disabled unless he or she furnishes proof of the existence thereof in such form and manner, and at such times as the Internal Revenue Service (IRS) may require. 7. Fund Shares Mutual Fund Shares which are offered through Prudential Mutual Fund Services LLC (PMFS) for investment of Custodial Account assets. 8. Participant Each individual who has signed the Application accompanying this Agreement and on whose behalf contributions are made. This Agreement governs the Participant's Prudential Mutual Fund Individual Retirement Account ("IRA"), and is made between the Participant and the Custodian to establish an individual retirement custodial account under Section 408(a) of the Code for the exclusive benefit of the Participant and his or her beneficiaries. ARTICLE II 1. Maximum permissible amount Except in the case of a qualified rollover contribution or a recharacterization (as defined in II.4 below), no contribution will be accepted unless it is in the form of a check or other instrument acceptable by the Custodian. The total of such contributions to all the Depositor's Roth IRAs for a taxable year cannot exceed the applicable amount (See Applicable Amount, under II.2(c) below), or the Depositor's compensation (as defined in II.6 below), if less, for that taxable year. The contribution described in the previous sentence that does not exceed the lesser of the applicable amount or the Depositor's compensation is referred to as a "regular contribution". It is the responsibility of the Depositor to determine whether any excess contribution has been made, the amount of the excess, the amount of any income earned on the excess contribution, and for the timely withdrawal or recharacterization of the appropriate amounts. A "qualified rollover contribution" is a rollover contribution of a distribution from an IRA that meets the requirement of Section 408(d)(3) of the Code, except the one-rollover-per-year rule of Section 408(d)(3)(B) does not apply if the rollover contribution is from an IRA other than a Roth IRA (a "non-roth IRA"). "). For taxable years beginning after 2005, a qualified rollover contribution includes a rollover from a designated Roth account described in Code Section 402A; and for taxable years beginning after 2007, a qualified rollover contribution also includes a rollover from an eligible retirement plan described in 402(c)(8)(B). Contributions may be limited under II.2 through II.3 below. However, notwithstanding the dollar limits on contributions, an individual may make a repayment of a qualified reservist distribution described in Section 72(t)(2)(G) during the 2-year period beginning on the day after the end of the active duty period or by August 17, 2008, if later. Filing Status Single or Head of Household Joint Return $150,000 or Qualifying or less Widow(er) Married- Separation Return Full Contribution $95,000 or less $0 Phase-out Range Modified AGI Between $95,000 & $110,000 Between $150,000 & $160,000 Between $0 & $10, Regular contribution limit If (a) and/or (b) below apply, the maximum regular contribution that can be made to all the Depositor's Roth IRAs for a taxable year is the No Contribution $110,000 or more $160,000 or more $10,000 or more smaller amount determined under (a) or (b), as applied to the applicable amount under (c) below. After 2006, the dollar amounts above will be adjusted for cost-of-living increases under Section 408(A)(c)(3). Such adjustments will be in multiples of $1,000. (a) The maximum regular contribution is phased out ratably between certain levels of modified adjusted gross income ("modified AGI," defined in (I.5) below) in accordance with the following table: If the Depositor's modified AGI for a taxable year is in the phase-out range, the maximum regular contribution determined under this table for that taxable year is rounded up to the next multiple of $10 and is not reduced below $200. (b) If the Depositor makes regular contributions to both Roth and non-roth IRAs for a taxable year, the maximum regular contribution that can be made to all the Depositor's Roth IRAs for that taxable year is reduced by the regular contributions made to the Depositor's non-roth IRAs for the taxable year. (c) Applicable Amount. The applicable amount is determined under (1) or (2) below: (1) If the Depositor will be under age 50 as of the end of the calendar year, the applicable amount is $3,000 for 2002 through 2004; $4,000 for years 2005 through 2007; and $5,000 for After 2008, the limit will be adjusted by the Secretary of the Treasury for costof-living increases under Code section 219(b)(5)(D). Such adjustments will be in multiples of $500. (2) If the Depositor will be 50 or older as of the end of the calendar year, the applicable amount is $3,500 for 2002 through 2004; $4,500 for 2005; $5,000 for 2006 and 2007; and $6,000 for After 2008, these limits will also be adjusted by the Secretary of the Treasury for cost-of-living increases under Code section 219(b)(5)(C). Such adjustments will be in multiples of $500. (3) If the individual was a participant in a Section 401(k) plan of a certain employer in bankruptcy described in Section 219(c)(5)(c), then the applicable amount under (1) above is increased by $3,000 for taxable years beginning after 2006 and before 2010 only. An individual who makes contributions under this paragraph may not also make contributions under paragraph (2). 1

18 Roth Individual Retirement Custodial Account Agreement 3. Qualified rollover contribution limit A rollover from an eligible retirement plan other than a Roth IRA or a designated Roth account cannot be made to this IRA if, for the year the amount is distributed from the other plan, (a) the Depositor is married and files a separate return, (b) the Depositor is not married and has modified AGI in excess of $100,000 or (c) the Depositor is married and the Depositor and the Depositor's spouse have modified AGI in excess of $100,000. For purposes of the preceding sentence, a husband and wife are not treated as married for a taxable year if they have lived apart at all times during that taxable year and file separate returns for the taxable year. For taxable years beginning after 2009, the income limits in this paragraph, do not apply to qualified rollover contributions. 4. Recharacterization A regular contribution to a non-roth IRA may be recharacterized pursuant to the rules in Section 1.408A-5 of the proposed regulations as a regular contribution to this Roth IRA, subject to the limits in (b) above. 5. Modified AGI For purposes of I.2 and I.3 above, an individual's modified AGI for a taxable year is defined in Section 408A(c)(3)(C)(I) and does not include any amount included in adjusted gross income as a result of a rollover from an eligible retirement plan other than a Roth IRA (a "conversion"). 6. Compensation For purposes of (I.1) above, compensation is defined as wages, salaries, professional fees or other amounts derived from or received for personal services actually rendered (including, but not limited to, commissions paid salesmen, compensation for services on the basis of a percentage of profits, commissions on insurance premiums, tips, and bonuses) and includes earned income, as defined in Section 401(c)(2) (reduced by the deduction the self-employed individual takes for contributions made to a selfemployed retirement plan). For purposes of this definition, Section 401(c)(2) shall be applied as if the term trade or business for purposes of Section 1402 included service described in subsection (c)(6). Compensation does not include amounts derived from or received as earnings or profits from property (including, but not limited to, interest and dividends) or amounts not includible in gross income. Compensation also does not include any amount received as a pension or annuity or as deferred compensation. The term "compensation" shall include any amount includible in the individual's gross income under Section 71 with respect to a divorce or separation instrument described in subparagraph (A) of Section 71(b)(2). In the case of a married Depositor filing a joint return, the greater compensation of his or her spouse is treated as his or her own compensation, but only to the extent that such spouse's compensation is not being used for purposes of the spouse making a contribution to a Roth IRA or a nondeductible contribution to a non-roth IRA. ARTICLE III No contributions will be accepted under a SIMPLE IRA plan established by any employer pursuant to Section 408(p). Also, no transfer or rollover of funds attributable to contributions made by a particular employer under its SIMPLE IRA plan will be accepted from a SIMPLE IRA, that is, an IRA used in conjunction with a SIMPLE IRA plan prior to the expiration of the 2-year period beginning on the date the individual first participated in that employer's SIMPLE IRA plan. ARTICLE IV The Participant's interest in the balance in the Custodial Account is nonforfeitable. ARTICLE V 1. No part of the custodial funds may be invested in life insurance contracts, nor may the assets of the Custodial Account be commingled with other property except in a common trust fund (within the meaning of Section 408(a)(5)). 2. No part of the custodial funds may be invested in collectibles (within the meaning of Section 408(m)). ARTICLE VI 1. Distribution upon death--at the customer's request and direction: The distribution of the Participant's interest in the account shall be made in accordance with the requirements of Code Section 408(a)(6), as modified by section 408A(c)(5), and the underlying regulations, which provisions are incorporated by reference. Upon the death of the Participant, the assets remaining in the Participant's Roth IRA become the property of the Particpant's named beneficiary. The Participant can name one or more primary beneficiaries and contingent beneficiaries, including individuals or entities, such as trusts or the Participant's estate, to receive any balance remaining in the Roth IRA at the Participant's death. The contingent beneficiaries named become beneficiaries of the Participant's Roth IRA only if no primary beneficiary survives the Participant, or if all primary beneficiaries disclaim their interest in the Account. If there is no designated beneficiary, or if none of the beneficiaries that are designated survive the Participant, then the balance in the Roth IRA will be paid to the Participant's surviving spouse or, if none, to the Participant's estate. Upon the death of the Participant, the balance in the IRA must be distributed at least as rapidly as follows: (a) If the designated beneficiary is someone other than the Participant's surviving spouse, the entire interest will be distributed, starting by December 31 of the year following the year of the Participant's death. The distributions would be made over the remaining life expectancy of the designated beneficiary. The designated beneficiary's life expectancy would be determined by using the age of the beneficiary as of his or her birthday in the year following the year of the Participant's death, or, if elected, in accordance with paragraph (c) below. (b) If the sole designated beneficiary is the Participant's surviving spouse, the entire interest will be distributed, starting by December 31 of the year following the year of the Participant's death (or by the end of the calendar year in which the Participant would have attained age 70 ½, if later). The distributions would be made over such spouse's life, or, if elected, in accordance with paragraph (c) below. If the surviving spouse dies before distributions are required to begin, the remaining interest will be distributed, starting by December 31 of the year following the calendar year of that spouse's death. The distributions would be made over the spouse's designated beneficiary's remaining life expectancy. This would be determined by using the spouse's designated beneficiary's age as of his or her birthday in the year following the death of the Participant's spouse, or, if elected, will be distributed in accordance with paragraph (c) below. If the Participant's surviving spouse dies after distributions are required to begin, any remaining interest will be distributed over that spouse's remaining life expectancy determined using the age as of his or her birthday in the year of the spouse's death. (c) If there is no designated beneficiary, or if applicable by operation of paragraphs (a) or (b) above, the entire interest will be distributed by December 31 of the year containing the fifth anniversary of the Participant's death (or of the death of the Participant's spouse in the case of the surviving spouse's death before distributions are required to begin under paragraph (b) above. The amount to be distributed each year under paragraph (a) or (b) is the amount obtained by dividing the value of the IRA as of the end of the preceding year by the remaining life expectancy specified in such paragraph. Life expectancy is determined using the Single Life Table in Q&A-1 of Section 1.401(a)(9)-9 of the Income Tax Regulations. If distributions are being made to a surviving spouse as the sole designated beneficiary, such spouse's remaining life expectancy for a year is a number in the Single Life Table corresponding to such spouse's age in the year, resulting in recalculation of the spouse's life expectancy. In all other cases, remaining life expectancy 2

19 Roth Individual Retirement Custodial Account Agreement for a year is the number in the Single Life Table corresponding to the beneficiary's age in the year specified in paragraphs (a) or (b) and reduced by one for each subsequent year. 2. No amount is required to be distributed prior to the death of the Participant for whose benefit the Custodial Account was originally established. 3. The value of the IRA includes the amount of any outstanding rollover, transfer and recharacterization under Q&As-7 and -8 of Section of the Income Tax Regulations. 4. If the sole designated beneficiary is the individual s surviving spouse, the spouse may elect to treat the IRA as his or her own IRA. This election will be deemed to have been made if such surviving spouse makes a contribution to the IRA or fails to take required distributions as a beneficiary. ARTICLE VII 1. The Participant agrees to provide the Custodian with information necessary for the Custodian to prepare any reports required under Sections 408(i) and 408A(d)(3)(D), Regulation Sections , , and any other appropriate sections, and under guidance published by the Internal Revenue Service. 2. The Custodian shall furnish annual calendaryear reports concerning the status of the Account and such information concerning required minimum distributions as is prescribed by the Commissioner of Internal Revenue. 3. The Participant is responsible for making all of the investment decisions relating to the assets in the Account. The Participant will direct us with regard to the investment and reinvestment of the IRA contributions and any investment earnings. The Participant may change any investment direction at any time. Upon the death of the Participant, the Beneficiary is responsible for making investment decisions for the Account. The Participant acknowledges and agrees that we, our agents, or employees do not have discretionary authority over the Account, and any investment decision is the sole responsibility of the Participant. The Participant further acknowledges and agrees that although we, our agents, or employees may provide research and other investment information from time to time as part of the brokerage services for the Account, such information does not affect the Participant's responsibility for controlling the investment decisions of the Account, nor does it make us a fiduciary of the Account. ARTICLE VIII Notwithstanding any other articles which may be added or incorporated, the provisions of Articles I through VI and this sentence will be controlling. Any additional articles that are not consistent with Section 408A, the related regulations, and other published guidance will be invalid. ARTICLE IX This Agreement will be amended from time to time to comply with the provisions of the Code, related regulations, and other published guidance. Other amendments may be made with the consent of the persons whose signatures appear on the application. ARTICLE X 1. Custodian Prudential Trust Company shall serve as the custodian of the IRA. 2. Amendments This Custodial Agreement is intended to be and to remain a qualified Roth Individual Retirement Account within the meaning of Section 408A of the Code. For the purpose of insuring the continued compliance of this Agreement with the requirements of applicable law, or of conforming it to statutory or regulatory changes in allowable contribution limits, this Agreement may be amended from time to time by written instrument delivered to the Custodian without the consent of the Participant. The Custodian also may make such other amendments to this Agreement from time to time as may be consistent with the provisions of applicable law, which amendments shall not be effective until the Custodian and the Participant have consented thereto. With regard to an amendment for which consent is required, no amendment to this Agreement shall vest any right or interest in the Custodial Account in any party other than the Participant, his or her spouse or beneficiaries, and any such amendments may be effective retroactively, provided that such amendment shall not deprive the Participant, his or her spouse or beneficiary of any benefit to which each may be entitled as a result of contributions made prior to the amendment. 3. Fiduciary responsibilities (a) The Custodian shall be responsible for the administration of the Custodial Account, shall receive all contributions, shall make distributions and pay benefits from the Custodial Account, shall file such statements or reports as may be required in the administration of the Custodial Account, and do other things as may be required in the administration of the Custodial Account. The Custodian shall maintain separate records for the interest of each individual. The Custodian, unless otherwise directed by the Participant and accepted by the Custodian, shall not make decisions with respect to the investment of Custodial Account assets. Unless otherwise directed, all dividends, including capital gain dividends, paid on Fund shares shall be reinvested in full and fractional shares of the mutual fund paying the dividend. (b) The Custodian shall use reasonable care, skill, prudence and diligence in the administration and investment of the Custodial Account and in executing any written instructions by the Participant, and shall be entitled to rely on information submitted by the Participant to the Custodian. 4. Termination by Custodian The Custodian may resign as Custodian and terminate this Agreement at any time upon 30 days' notice to the Participant. If no successor to the Custodian is designated by the Custodian, or if such successor is not acceptable to the Participant, the Participant shall appoint a qualified successor custodian or trustee. Upon acceptance by the successor, the Custodian shall pay, transfer and deliver to the successor the balance of the Participant's Account after deducting any fees payable and due. If no successor has accepted its appointment at the time the Custodian's resignation is to become effective, the Custodian reserves the right to pay, transfer and deliver such amount to the Participant. The balance of any amount deemed necessary by the Custodian to be held in reserve to cover any expense or liability constituting a charge against the account shall not be so paid, transferred or distributed until satisfaction of such charge. 5. Substitution of Custodian The Custodian will substitute another custodian or trustee if notified by the Commissioner of Internal Revenue that such substitution is required because the Custodian has failed to comply with the requirements of Section (e) of the Income Tax Regulations, or are not keeping records, making returns, or rendering statement as required by law. ARTICLE XI 1. Arbitration agreement Please be aware of the following: (a) Arbitration is final and binding on the parties. (b) The parties are waiving their rights to seek remedies in court, including the right to jury trial. (c) Pre-arbitration discovery is generally more limited than and different from court proceedings. (d) The arbitrators' award is not required to include factual findings or legal reasoning, and any party's right to appeal or to seek modification of rulings by the arbitrators is strictly limited. (e) The panel of arbitrators will typically include a minority of arbitrators who were or are affiliated with the securities industry. 3

20 Roth Individual Retirement Custodial Account Agreement The Participant agrees that all controversies that may arise between us concerning any transaction relating to this Agreement or the Participant's Account, to transactions with or for the Participant's Account, or any breach of this or any other agreement between us (whether executed or to be executed within or outside of the United States), whether entered into prior, on, or subsequent to the date indicated on the signature page of the Prudential IRA Application shall be determined by arbitration. Such arbitration may be before either the New York Stock Exchange, Inc. or the National Association of Securities Dealers, as the Participant may elect and shall be governed by the laws of the State of New York. If the Participant does not make such election by registered mail addressed to Prudential, at Prudential's main office within five (5) days after demand by us that the Participant make such election, then Prudential may make such election. Any notice in connection with such arbitration proceeding may be sent to the Participant by mail, and the Participant hereby waives personal service. Judgment upon any award rendered by the arbitrators may be entered in any court having jurisdiction, without notice to the Participant. No person shall bring a putative or certified class action to arbitration, nor seek to enforce any pre-dispute arbitration agreement against any person who has initiated in court a putative class action; or who is a member of a putative class who has not opted out of the class with respect to any claims encompassed by the putative class action until: (i) the class certification is denied; (ii) the class is decertified; or (iii) the customer is excluded from the class by the court. Such forbearance to enforce an agreement to arbitrate shall not constitute a waiver of any rights under this Agreement except to the extent stated herein. In witness whereof, the Participant has signed the IRA Application for this Roth Individual Retirement Custodial Account to evidence their acceptance on the date and year written on the IRA Application, which is made part of this Agreement. 4