SIMPLE IRA Withdrawal Authorization by idz16791

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									                                                                                      SIMPLE IRA Withdrawal Authorization
                                                                                                          SIMPLE IRA toll-free Customer Service:
    Use this form to request a reportable distribution from your SIMPLE IRA.                                  (800) 298-1345, 8:30 a.m. – 6:00 p.m.
    Do not complete this form if you are requesting a trustee to trustee transfer of assets.                Eastern Time, Monday through Friday

1   Participant Information (If you are a beneficiary, please complete an application and attach it to this form.)
    Name (please print your full name as it appears on your SIMPLE IRA)


    Mailing address (including apartment or box number)


    City                                                                                        State     ZIP code                  4-digit ext.


    Social Security number                         Date of birth
                                                                                                *This form may only be used for one account.
                                                                                                 If you have another account from which you
    Account number*                                Initial participation date                    wish to take distributions, please fill out a
                                                                                                 separate form.


2   Reason for Distribution (Check the box that applies.)
    If you have not participated in the SIMPLE IRA 2 years, and are under 59½, an IRS penalty may be imposed.
        1. Normal distribution – If you are the participant and age 59½ or older.
        2. Early (premature) distribution – If you are the participant and are under age 59½ or the distribution is due to medical expenses,
           health insurance premiums, higher education expenses, first time homebuyer expenses, or other reason.
        3. Substantially equal periodic payments within the meaning of section 72(t) of the Internal Revenue Code.
        4. Death – If you are a beneficiary, please contact us at the above referenced toll free Customer Service number for additional
           document requirements.
        5. Permanent disability – By checking this box, I certify that I meet the Internal Revenue Service's definition of disabled under
           section 72(m)(7) of the Internal Revenue Code, which requires that an individual be unable to engage in any substantial gainful
           activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or to
           be of long-continued and indefinite duration. If at some point you no longer meet this definition, you are required to notify
           Prudential in writing at the address on page 3 of this form.
        6. Transfer incident to divorce or legal separation – Please contact us at the above referenced toll free Customer Service
           number regarding additional document requirements.
    *Revocation – Please refer to the Disclosure Statement regarding your revocation rights.
    All required documentation must be received in good order before the distribution request will be honored. All legal documents must
    be certified and a Medallion Signature Guarantee may be required for the SIMPLE IRA owner, beneficiary or spouse.

3   Payment Method (All checks will be made payable to the registered account owner or beneficiary of record.)
    Please select one of the following four options.
       1. Total distribution of all funds within my account that was provided above.
       2. Partial distribution redeemed pro-rata across all funds: $                                    or Number of shares
       3. Partial distribution redeemed as follow:
       Share                                                                                     Number
       class      Fund name                                                                      of shares                 Amount
                                                                                                                 or    $
                                                                                                                 or    $
                                                                                                                 or    $
                                                                                                                 or    $
                                                                                                                 or    $
                                                                                        Total                    or    $


    SM 113970           Ed. 2/2010                                      Page 1 of 3
3   Payment Method (continued)
       4. Establish a Systematic Withdrawal Plan on your SIMPLE IRA and distribute the following amount:
          $                               or Number of shares

          Start Date
          Frequency (choose one) :        Monthly       Quarterly     Semiannually       Annually
          Choose one:
               Redeem pro-rata across all funds in my account
               Redeem from the funds listed below. Note: If no fund selection is indicated, the distribution will be redeemed pro-rata
               across all funds with balances.
       Share                                                                                  Number
       class       Fund name                                                                  of shares               Amount
                                                                                                            or    $
                                                                                                            or    $
                                                                                                            or    $
                                                                                                            or    $
                                                                                                            or    $
                                                                                      Total                 or    $
    Payment Mailing Instructions
    Please select one of the following three options.
       1. Mail to my address of record currently on file
       2. Mail to the following address*
       Name


       Care of (c/o)


       Mailing address (including apartment or box number)


       City                                                                               State       ZIP code             4-digit ext.


       3. Mail to the following financial institution address*
       Name of financial institution                                                                  Account number


       Mailing address (including suite or box number)


       City                                                                               State       ZIP code             4-digit ext.


    *Medallion Signature Guarantee required. (Check is still made payable to account owner, even when mailed to another address.)

4   Withholding Election (IMPORTANT: Please read this section carefully as the information has changed.)
    The taxable portion of the withdrawal that you receive will be subject to federal income tax withholding and 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 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.
                                                                                                                               (continued)
    SM 113970            Ed. 2/2010                                     Page 2 of 3
4   Withholding Election (continued) (IMPORTANT: Please read this section carefully as the information has changed.)
    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               % (minimum 10 percent) or
           Dollar amount $                 ,             .            (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               % or
           Specific dollar amount $                ,              .
    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.

5   Signature
    I certify that I am the participant authorized to make these elections and that all information provided is true and accurate. I further
    certify that the Custodian, Prudential, or the agent of either of them has given no tax or legal advice to me, and that all decisions
    regarding the elections made on this form are my own. The Custodian is hereby authorized and directed to distribute funds from my
    account in the manner requested. The Custodian may conclusively rely on this certification and authorization without further
    investigation or inquiry. I expressly assume responsibility for any adverse consequences which may arise from the election(s) and
    agree that the Custodian, Prudential, and their agents shall in no way be responsible, and shall be indemnified and held harmless, for
    any tax, legal or other consequences of the election(s) made on this form. If I am fully redeeming my account before the annual
    custodial maintenance fee has been assessed, I understand that the fee will be deducted from my distribution amount. I have read
    and understand and agree to be legally bound by the terms of this form. This form may only be used for one account. If you have
    another account from which you wish to take distributions, please fill out a separate form.

     Sign here    X                                                                                 Date
                     Participant’s signature (beneficiary’s signature if participant is deceased)


                                                                          *The Medallion Signature Guarantee may be executed by banks,
                                                                           broker dealers, credit unions, national securities exchanges and
                                                                           savings associations which participate in STAMP, SEMP or
                                                                           NYSE-MSP. A notary public is not a substitute for a Medallion
                                                                           Signature Guarantee. The Medallion Signature Guarantee stamp
                                                                           must include the words "SIGNATURE GUARANTEED,
                                                                           MEDALLION GUARANTEED" and otherwise comply with the
                                                                           medallion program requirements. Please check your fund
                                                                           prospectus or with your fund as to whether a signature
                                                                           guarantee is required.
      Signature Guarantee – Medallion Stamp* (if required)



    When complete, please return this form to:
    First class   Prudential                                      Overnight     Prudential
    mail:         c/o PFPC SIMPLE IRA                             mail:         c/o PFPC SIMPLE IRA
                  PO Box 9826                                                   101 Sabin Street
                  Providence, RI 02940-8026                                     Pawtucket, RI 02860

    SM 113970            Ed. 2/2010                                      Page 3 of 3

								
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