Questions? Call Prudential Retirement at (fax: )

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1 IRA Application For Prudential use only: Questions? Call Prudential Retirement at (fax: ) Office F Choose type of IRA Rollover 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. Traditional IRA Roth IRA Beneficiary IRA Personal information Account holder name Social Security no. Home phone no. Driver s license no. State Issue date / / Expiration date or passport no. State Country Expiration date / / / / of birth Mailing address / / City State ZIP code Legal address (If mailing address is a PO Box, you must provide a legal street address.) City State ZIP code U.S. citizen Yes No Other Non-resident alien? (If yes, W-8 Form is required.) Yes No Marital status: Single Married Widowed Divorced Number of dependents Additional information Occupation Employed by Business street address (PO Box not allowed) Business phone no. (Required) 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. Accounts are carried by National Financial Services LLC, member NYSE/SIPC. 1

2 Personal information (continued) Account information Do you have an existing account with Prudential Investment Management Services LLC (PIMS)? c Yes c No If yes, please indicate the account number(s): Account number(s) Please indicate whether the PIMS account(s) listed above 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 PIMS. The investor may not realize the full breakpoint opportunity available without this information. Account number(s) Affiliation disclosure (Please complete the section below) Are you affiliated with or employed by a member firm of a stock exchange or FINRA; 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? c Yes c No If yes, list company name and position Are you a director, a 10% shareholder, or a policy-making executive officer of a publicly traded company? 2 c Yes c 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. Ranges Annual income (all sources) Check one box in each column. See definitions below if you have any questions. Ranges Net worth (assets minus liabilities) Liquid net worth (exclude non-liquid assets) $0 24,999 c $0 49,999 c c $25,000 49,999 c $50,000 99,999 c c $50,000 99,999 c $100, ,999 c c $100,000 + c $500,000 + c c 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. 2

3 Client profile information (continued) Investment objectives Please rank your investment objectives in order as they relate to the assets in your brokerage account from 1 (most important) to 5 (least important). c Preservation of capital c Income c Capital appreciation c Speculation c Trading profits Investor style Please select ONE description that best represents your investment approach to this account. c 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. c Moderate Willing to assume an average amount of market risk and volatility or loss of principal to achieve higher returns. c 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. (If no experience, please enter zero.) c Equities c Options c Bonds c Variable contracts c Mutual funds c Limited partnerships Years to retirement Please indicate the number of years until you will begin taking distributions from this retirement account. c 0 5 years c years c 6 10 years c 16+ years Source of funds for this account Please indicate the source of funds for this IRA below. (If making a contribution by check, please skip to Section 4 and select the appropriate choice.) c 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 c Plan maintained by an external service provider (NOT Prudential) c Individual Retirement Account (IRA) 3

4 3 How will this IRA be initially funded? (Choose one) Important note: Accounts with balances below $1,000 may be closed at our discretion c Contribution check enclosed for $ for tax year c Check enclosed for $ to be treated as a 60-day rollover from another retirement plan or IRA c Direct transfer of an IRA from another financial institution (Please complete and submit a transfer form*) c Direct rollover from a tax-qualified retirement plan 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 $ c Conversion of assets from a PIMS Traditional or Rollover IRA to a PIMS 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 $ c Conversion of assets from a Prudential Retirement IRA for a deceased individual to PIMS beneficiary IRA number (of deceased individual s IRA) c Other (please specify) 4 *Specific forms can be obtained by calling Prudential Retirement at Investment selection If an investment selection is not made, your assets will be invested in the Money Account. c 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. c OPTION 2 Check here if funds are being transferred in kind from another account. 4

5 5 Beneficiary designation Please select a Primary Beneficiary(ies). Percentages must equal 100% You may also select a Contingent Beneficiary(ies). These percentages must also equal 100% Primary Beneficiary Contingent Beneficiary, if any Name Relationship Address City Name Relationship Address City State Zip code State Zip code Social Security no. Social Security no. of birth % of birth % Primary beneficiary, if any Contingent beneficiary, if any Name Relationship Address City Name Relationship Address City State Zip code State Zip code Social Security no. Social Security no. of birth % of birth % Primary beneficiary(ies) percentages must total 100% Contingent beneficiary(ies) percentages must total 100% 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%, 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 70½, changing the beneficiary designation to a beneficiary with a shorter life expectancy may affect the Required Minimum Distributions (RMD) 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. Signature of spouse 5

6 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 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. By signing on page 7, under penalties of perjury, I certify that I am an individual, a U.S. citizen or other U.S. person (as defined in Form W-9), and that the Social Security number I have provided in Section 1 is correct. (NOTE: failure to provide a correct Social Security number may subject my account to backup withholding.) I understand that if I am a nonresident alien, I am required to complete Form W-8BEN to certify my foreign status and I understand that I am not under penalty of perjury certifying the above information. Please contact us to obtain Form W-8BEN. 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 the Prudential representative with whom I spoke about the Prudential IRA is a registered representative of PIMS, LLC who will receive compensation if I decide to either roll over my plan account to an individual retirement account (or IRA ) through Prudential or keep my funds in my employer-sponsored retirement plan. The timing and amount of these compensation payments for an IRA rollover is more favorable than for remaining in the plan. Should I choose to roll to an IRA through Prudential, such compensation does not differ based on which IRA I choose or how my money is invested. I understand that I have the option to maintain my account balance under my former employer s plan instead of rolling my account balance to an IRA, and that the fees associated with remaining in the plan will be different from, and are likely to be less than, the fees of the Prudential IRA. I understand that I can contact Prudential Retirement at to obtain a comparison of fees between my former employer s plan and a Prudential IRA. I understand that Prudential is very likely to earn more revenue if I roll my funds to a Prudential IRA than if I maintain my account balance under my former employer s plan. I understand that if I remain in my former employer s plan, the investment choices are selected by a party that has a fiduciary obligation to act in my best interest. I understand that the Prudential IRA is not affiliated with any employer-sponsored plan or plan sponsor, and a rollover to an IRA means I am no longer part of an employer-sponsored plan. Once assets are rolled over to an IRA, they normally cannot be rolled back to a former employer s plan. 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. The securities in your account are protected in accordance with the Securities Investor Protection Corporation (SIPC). For more details on SIPC, or to request a SIPC brochure, visit or call 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 will be charged the following fees: The SelectPlatform 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 SelectPlatform, is available in the current version of the Brokerage Services Investor s Toolkit. To obtain a copy, please call or visit The fees related to investments in these funds are described below. SelectPlatform funds administrative fee:* A tiered administrative fee will apply to all purchases of SelectPlatform mutual funds based on your Prudential Retirement account balance(s) at the time of the trade. Fee* Account balance 1.75% up to $99, % from $100,000 to $249, % from $250,000 to $499, % from $500,000 to $999, % for $1,000,000 plus * 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 other IRA investments (such as an equity or bond) or from any mutual fund outside the same fund family and used to purchase SelectPlatform mutual fund shares. SelectPlatform Funds Available through Rollover IRAs only. Purchases of funds offered by these families are available to Prudential Retirement brokerage IRA clients at Net Asset Value (NAV) from our fund partners. Load waiver, where applicable, is only available to accounts rolled over from a retirement plan where Prudential is recordkeeper. 6

7 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 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 Other share classes of these funds may have a lower expense ratio, but the funds we have chosen to make available on the SelectPlatform may not include such shares in order to compensate us for distribution and account servicing. Please review the applicable fund s prospectus for additional information. Mutual funds outside the SelectPlatform In addition to the funds on the SelectPlatform, other mutual funds are available for investment within an IRA. 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 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 s Toolkit. I understand that the Customer Agreement contains a pre-dispute clause (section 15, page 5) 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 Print Account Holder name For Prudential use only: Signature of registered representative Print Name of registered representative Signature of supervisory principal Print name of supervisory principal Office F72 Reg. rep. no. Account no. account opened 7

8 RETURN STANDARD MAIL TO: Prudential Retirement PO Box 5320 Scranton, PA RETURN OVERNIGHT MAIL TO: Prudential Retirement 30 Scranton Office Park Scranton, PA FAX TO: Securities products are not FDIC insured/not bank deposits/may lose value Securities products and services are offered by Prudential Investment Management Services LLC (PIMS), Three Gateway Center, 14th Floor, Newark, NJ , a Prudential Financial company. Retirement Counselors are registered representatives of PIMS. Prudential, the Prudential logo, and the Rock symbol are service marks of Prudential Financial, Inc. and its related entities, registered in many jurisdictions worldwide. 30 Scranton Office Park Scranton, PA ROFM011 Printed 04/2012

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