USA PATRIOT Act
Customer Identity Verification
For assistance:
Clients: (800) 225-1852
Pruco representatives: (800) 542-7117
Prudential Mutual Fund Services LLC, (PMFS)
a Prudential Financial company
Patriot Act Identity Verification
To be completed by registered representatives of Pruco Securities only. Please print using blue or black ink.
To help the government fight the funding of terrorism and money laundering activities, PMFS 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, PMFS will be able to fully service and maintain the account.
1
Owner's ID Verification For Natural Persons
Name of owner (First, MI, Last name)
Account number (if known)
or Social Security number
Owner Information
Personally met, ID documents reviewed
ID documents not present
Not personally met
ID Verification Documentation
State DMV issued ID Number
Exp. date
Issuing state
Passport
Number
Exp. date
Issuing country
U.S. Visa
Number
Exp. date
U.S. Alien ID Card
Number
Exp. date
Name of joint owner(First, MI, Last name)
Joint Owner Information
Personally met, ID documents reviewed
ID documents not present
Not personally met
ID Verification Documentation
2
State DMV issued ID Number
Exp. date
Issuing state
Passport
Number
Exp. date
Issuing country
U.S. Visa
Number
Exp. date
U.S. Alien ID Card
Number
Exp. date
Owner's ID Verification For Entity Ownership
Name of entity
Form of Ownership
Trust (Trust document must be reviewed.)
Date of trust
month / day / year
Trustee name
Trustee address
Corporation
MF1026
LLC
Ed. 10/2007
Partnership
Charity
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Other
(continued)
2
Owner's ID Verification For Entity Ownership (continued)
Documents Reviewed
U.S. or state government-issued business license used for verification
License #
Issuing entity
License date
month / day / year
Articles of Incorporation
Other (describe)
Partnership Agreement
State of formation/organization
LLC Operating Agreement
Date of formation/incorporation
month / day / year
No official document available
3
Client Signature(s)
I acknowledge that any identity information I have provided may be confirmed via an external verification entity.
Client name(s) (please print)
X
Client’s signature
month / day / year
Client’s signature (if applicable)
month / day / year
X
4
Registered Representative Signature
I certify that to the best of my knowledge, the information provided by the owner(s) and/or legal representative(s)
above accurately reflects the identity of the owner(s), and that if the owner is an entity, I have viewed the actual
business document(s) relied upon for the verification, if indicated. I further certify that to the best of my knowledge,
all information contained in this form is true, accurate, and complete and that the ID Verification Notice has been
provided to all owner(s) and/or legal representative(s).
Name (please print)
Office telephone
X
Registered representative’s signature
month / day / year
Registered representative’s number
Please return this entire form with the application or submit it to one of the addresses below if the original
application has already been sent to PMFS.
Standard
mail to:
Prudential Mutual Fund Services LLC
PO Box 9658
Providence, RI 02940
Overnight Prudential Mutual Fund Services LLC
mail to:
101 Sabin Street
Pawtucket, RI 02860
If you have questions, please call the Prudential Mutual Fund Service Center at (800) 225-1852, Monday through
Friday between 8:00 a.m. and 8:00 p.m. Eastern time.
MF1026
Ed. 10/2007
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