Request for 403(b) Distribution
Prudential Mutual Fund Services LLC
Prudential Trust Company
Both are Prudential Financial companies.
Instructions
Use this form to request a distribution from your Prudential Trust Company 403(b) account.
Do not use this form if you are requesting a company-to-company transfer of assets into another 403(b). In
cases of death, we request an Affidavit of Domicile. An Inheritance Tax Waiver may also be required,
depending on the decedent's state of residence.
Please follow these steps:
1. Please submit a separate request for each account.
2. Read the accompanying Special Tax Notice (pages 9 through 15) before completing this form.
Note: This form is only valid for 180 days. If more than 180 days has elapsed from the date you
received this form, please contact the Prudential Mutual Fund Service Center at the number listed
below to obtain a current form and Special Tax Notice.
3. Obtain a Signature Guarantee, if needed, based on the instructions in section 8.
4. Print using blue or black ink. Sign and date your request in section 8 and section 10.
5. Have your employer complete, sign and date section 9.
6. If you are requesting a direct rollover, you must attach the receiving company's direct rollover paperwork.
7. If you need assistance completing this form, please call the Prudential Mutual Fund Service Center
at (800) 225-1852, Monday through Friday between 8:00 a.m. and 6:00 p.m. Eastern time.
Mailing
Instructions
MF1005
Standard Prudential Mutual Fund Services LLC
mail to:
PO Box 9658
Providence, RI 02940
Ed.10/2011
Page 1 of 12
Overnight Prudential Mutual Fund Services LLC
mail to:
4400 Computer Drive
Westborough, MA 01581
Request for 403(b) Distribution
Prudential Mutual Fund Services LLC
Prudential Trust Company
Both are Prudential Financial companies.
1
Participant
Information
Name of participant (first, middle initial, last name)
Street
Apt.
City
State
Zip code
Daytime telephone number
Extension
Home telephone number
Social Security number (optional)
Account number (required)
Date of birth (mo., day, year)
2
Request for
Distribution
Please check one of the following two options:
o I would like a lump sum distribution. Please distribute the total amount in all funds.
o I would like a partial distribution. Please process my distribution in the following manner:
Share class (A, B, or C)
Fund name
Dollar amount $
Please check one: o Net*
or Percent
o Gross*
Share class (A, B, or C)
Fund name
Dollar amount $
Please check one: o Net*
or Percent
Share class (A, B, or C)
Dollar amount $
or Percent
% or Share amount
o Gross*
Share class (A, B, or C)
Fund name
Dollar amount $
Please check one: o Net*
% or Share amount
o Gross*
Fund name
Please check one: o Net*
% or Share amount
or Percent
% or Share amount
o Gross*
*If you request a net amount, you will receive a check for that amount. Any applicable fees, contingent
deferred sales charge, and income tax withholding will be applied by redeeming additional shares.
Sufficient shares must be available to cover these charges. A request for a gross amount would result in
a check for the specified dollar amount minus any fees, charges, and taxes.
MF1005
Ed.10/2011
Page 2 of 12
3
Reason for
Distribution
Amounts distributed to you will be reported to the Internal Revenue Service (IRS) as income. If you are
under age 59½, checking a box below will not necessarily exempt you from the 10 percent federal income
tax penalty on early distributions. You will need to determine if you are exempt from this tax penalty and, if
so, you must submit the necessary forms when filing your federal income tax return. Please note that in
order to process a direct rollover you must choose an eligible reason for distribution below.
Please check one:
1. ¨ Normal distribution (i.e., distribution after age 59½).
2. ¨ Distribution to a spousal beneficiary due to death (employer certification is not required).
3. ¨ Distribution to a non-spousal beneficiary due to death (employer certification is not required).
4. ¨ Distribution due to disability.
• By checking this box I certify that I meet the IRS definition of disabled, 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 Mutual
Fund Services, LLC (PMFS, LLC) in writing at the address at the end of this form.
5. ¨ Distribution due to voluntary or involuntary separation from service (i.e. quits or termination of
employment) before attaining age 59½.
6. ¨ Distribution due to Qualified Domestic Relations Order (QDRO) to a spouse or former spouse.
(Provide a certified copy of the QDRO.)
7. ¨ Distribution due to Qualified Domestic Relations Order (QDRO) to a child or other dependent.
(Provide a certified copy of the QDRO.)
8. ¨ Distribution due to an excess contribution. Please indicate the date that the first excess deferral
was applied to your account:
.
Note: If it is past April 15th of the year following the year in which the excess occurred, you must
also satisfy and select one of the other reasons listed on this page (in addition to selecting reason
8) in order to remove your excess contribution.
9. ¨ Required Minimum Distribution (i.e., distribution after either reaching the age of 70½ or retirement,
whichever is later, under the Required Minimum Distribution rules).
Please check one:
A. ¨ Based on my life expectancy and IRS tables.
B. ¨ Based on my life expectancy and my spouse’s life expectancy. (Available when your spouse
is the sole beneficiary and is more than 10 years younger than you.)
Spouse’s date of birth (mo., day, year)
10. ¨ Financial Hardship
I certify that my employer has determined by checking this box and signing below this distribution
is necessary to satisfy an immediate and heavy financial need, as described in the Internal
Revenue Code and the accompanying regulations, which cannot be satisfied from insurance,
reasonable liquidation of my assets, cessation of elective deferrals to my 403(b), or other
distributions or loans from my employer’s plans or a commercial loan. I understand that this
distribution cannot exceed the amount necessary to satisfy the financial need and may only be
made from salary deferral amounts and not the earnings attributable to them. IRS regulations
require that further contributions be prohibited for a period of six months from the date of the
withdrawal.
MF1005
Ed.10/2011
Page 3 of 12
3
Reason for
Distribution
(continued)
4
Eligible
Rollover
Distribution
Information
Do not
complete this
section if your
distribution is
not eligible for
rollover.
11. ¨ Plan Termination Termination Date
A letter from your employer on company letterhead is required stating “I the employer certify that
the 403(b) plan of (name of plan) is being terminated according to the final Internal Revenue Code
Section 403(b) regulations released on July 23, 2007.”
The following types of distributions are not eligible to be rolled over:
• Distribution due to an excess contribution
• Distribution due to financial hardship
• Distribution due to QDRO to a non-spouse
• Required Minimum Distribution
If you would like to directly roll over all or a portion of your eligible rollover distribution, please check the
appropriate boxes below, check off an eligible reason in box 3 that qualifies for a rollover distribution and
attach the receiving company’s direct rollover paperwork to this form. Please note: if you do not have an
eligible reason for distribution, we will be unable to complete your direct rollover request.
• Direct rollover to (Please check one.)
o Inherited IRA (spouse beneficiary)
o IRA o Qualified plan or governmental 457 plan
o Inherited IRA (non-spouse beneficiary) o Roth IRA
• I have already attained or will attain the age of 70½ in the year in which I am requesting this direct rollover.
(Please check one.) o Yes o No (If No, please skip the remaining part of this section.)
• I am retired. (Please check one.) o Yes o No (If No, please skip the remaining part of this section.)
• I have satisfied the Required Minimum Distribution for the current tax year. (Please check one.)
o Yes (If Yes, please skip the remaining part of this section.) o No
• I direct PMFS, LLC to distribute $
which represents my Required Minimum Distribution
for the current year. You should consult with your tax adviser for help in calculating this amount.
Note: The IRS imposes strict penalties on individuals for failure to receive their Required Minimum
Distribution. Prudential will not be responsible for any penalties imposed by the IRS.
For Roth IRA Restrictions: A distribution from a 403(b) may be directly rolled over to a Roth IRA (sometimes
referred to as converting to a Roth IRA) or the amount can be distributed and rolled over to a Roth IRA within
60 days after the funds are received. The amount rolled over must be an eligible rollover distribution.When
counting days, weekends and holidays are included. “Day 1” is the day after the distribution is received.
There are generally no exceptions to the 60-day rule and the IRS generally will not grant extensions.
TWELVE MONTH RESTRICTION: You are entitled to take one distribution from your Roth IRA every 12
months for purposes of being rolled over to another Roth IRA.
AGE RESTRICTION: Rollovers made during the calendar year following the later of (a) the year in which the
participant attains age 70½, or (b) retires, cannot be made from assets representing a required minimum
distribution.
INCOME RESTRICTION: If your adjusted gross income for the tax year exceeds $100,000 (single or married
filing joint return), you are not eligible to rollover (directly or indirectly) your 403(b) to a Roth IRA during such
year.The income restriction is eliminated after 2009.
TAX RETURN RESTRICTION: If you are married and you and your spouse file separate tax returns for any
given year, you are not eligible to rollover directly or indirectly your I403(b) to a Roth IRA during such year.
I understand that the eligible rollover portion of any distribution not directly rolled over will be subject to
a mandatory 20 percent federal income tax withholding, as described in section 7 and the attached
Special Tax Notice.
MF1005
Ed.10/2011
Page 4 of 12
5
Recipient
of
Distribution
Complete the information below only if part or all of the distribution is being made to someone other
than the participant. If a distribution is being made to more than one recipient, indicate the amount going
to each.
Distribution is to be made to:
Name of (Please check one:) o beneficiary o trustee o custodian
Street
Apt.
City
State
Social Security number
Zip code
Account number (if distribution is made payable to a trustee or custodian)
Fund name (if applicable)
Amount
$
or
Percentage
%
Name of (Please check one:) o beneficiary o trustee o custodian
Street
Apt.
City
State
Social Security number
Zip code
Account number (if distribution is made payable to a trustee or custodian)
Fund name (if applicable)
Amount
6
Bank
Account
Information
$
or
Percentage
%
Complete this section only if you would like the distribution to be sent electronically to your bank. The
distribution amount must be greater than $1,000 to have your money wired to your bank account.
You must attach a voided check.
Note: The same name must appear on both your 403(b) account and the bank account specified below.
Type of account
Attach voided
check here.
¨ Checking
¨ Savings
Bank name
Bank account number
ABA routing number (To ensure accuracy, verify with bank.)
Local branch telephone number
Name of depositor on bank records (first, middle initial, last name)
Name of joint depositor on bank records (first, middle initial, last name)
MF1005
Ed.10/2011
Page 5 of 12
7
Federal and
State Income
Tax
Withholding
Federal tax laws require us to withhold income taxes from the taxable portion of a qualified retirement plan
distribution. Some states also require withholding from the taxable portion of your distribution, if federal
income tax is withheld.
The eligible rollover portion of your distribution is subject to a mandatory 20 percent federal income tax
withholding unless directly rolled over to a traditional IRA, another 403(b) plan, a 457 (governmental) plan,
or another plan qualified under Internal Revenue Code section 401(a). Please read the attached Special
Tax Notice regarding eligible rollover distributions.
The taxable portion of your distribution that is not eligible for rollover (for example, a Required Minimum
Distribution or a distribution due to an excess contribution) is subject to a voluntary 10 percent federal
income tax withholding unless you elect otherwise. You can elect to have no federal taxes withheld on the
portion of your distribution not eligible for rollover by checking the first box below. If you elect out of
withholding, you are still responsible for payment of taxes due, and you may incur penalties if your
withholding and/or estimated tax payments are not sufficient.
If you do not check the option below, a 10 percent federal income tax withholding will be automatically
deducted from this portion of your distribution. When federal income tax is withheld, we will also withhold
state income tax as required by certain states.
For distribution due to death to a non-spouse beneficiary, distribution due to QDRO to a non-spouse,
distribution due to an excess contribution, Required Minimum Distribution, distribution due to financial
hardship ONLY:
o Do not withhold federal and state income taxes from the taxable portion of my distribution not eligible for
rollover (if any).
o Withhold federal and state income taxes, as indicated below, from the taxable portion of my distribution not
eligible for rollover.
Federal income tax
Dollar amount $
or Percentage
% (10 percent minimum)
State income tax (Amount withheld must meet state minimum.)
Dollar amount $
8
or Percentage
%
Authorization You must have your signature medallion signature guaranteed under the following circumstances:
and
• If the distribution exceeds $10,000 and is payable to a special payee or is mailed to a special address
Signature
(other than Prudential).
Guarantee
• If the distribution exceeds $100,000.
• If the distribution is mailed to a special address that is a P.O. Box, regardless of the dollar amount.
• If the distribution is made by wire and payable to a special payee (other than Prudential), regardless of
the dollar amount.
• If the distribution is due to the death of the account owner or on behalf of the account owner, a
medallion signature guarantee is required, regardless of the dollar amount.
The medallion signature guarantee may be obtained from an authorized officer from a bank, broker,
dealer, securities exchange or association, clearing agency, savings association, or credit union that is
participating in one of the recognized medallion programs (STAMP, SEMP, or NYSE MSP). The medallion
signature guarantee must be appropriate for the dollar amount of the transaction. Prudential Mutual Fund
Services LLC reserves the right to reject transactions where the value of the transaction exceeds the
value of the surety coverage indicated on the medallion imprint.
(continued)
MF1005
Ed.10/2011
Page 6 of 12
8
Authorization
and
X____________________________________________________
Signature
Participant’s signature
Guarantee
(continued)
Date
X____________________________________________________
Beneficiary’s signature (if applicable)
Date
X____________________________________________________
Authorized signature (if applicable)
Date
Important: If you are acting on behalf of the account owner, please indicate the capacity in which you are
acting by checking the appropriate box below. If the correct box is not listed, please check “Other” and
specify your capacity.
o Administrator / Executor
o Beneficiary
o Appointee under POA
o Other, please specify
Place
medallion
signature
guarantee
here
Please be sure to check the box below if applicable.
¨ I certify that employer sign off is not needed since my custodial account maintains an exempt or
grandfathered custodial account for which no salary deferral contributions’ have been deposited after
December 31, 2004 and no incoming transfers after September 24, 2007. I understand by marking this
election that I may be required to provide proof of such exemption to the extent that JennisonDryden
Mutual Funds or Prudential Trust Company does not maintain adequate records to confirm such
exemption, which may delay this distribution. **Please note if you checked off financial hardship in
section 3 number 10, employer sign off will still be required.
9
Employer,
Employer, Authorized Signer Name
Authorized
Signer
Employer, Authorized Signer Address
Certification
City
State
Telephone number
Zip code
Extension
X____________________________________________________
Employer, Authorized signature and Title
Date
By signing the employer confirms that the conditions for this withdrawal, as indicated in this form, have
been met.
MF1005
Ed.10/2011
Page 7 of 12
10
Signature(s),
Waiver
and Tax
Certification
By signing below I certify that the information provided on this form regarding my status with respect to the
account involved and in all other aspects is correct. I also certify that the action directed on this form fully
complies with the terms of the applicable custodial agreement. There may be tax implications as a result of
this request(s) and the request(s) (including tax reporting and withholding) cannot be reversed once
processed. Please consult tax and/or legal counsel before proceeding.
I understand that a contingent deferred sales charge (CDSC) may be applied to Class B and Class C shares.
(For more information, please consult the relevant fund prospectus.)
I have read the attached Special Tax Notice, and I understand that I have 30 days following receipt of the
Special Tax Notice to decide whether or not I want a direct rollover. I also understand that my return of this
signed Request for 403(b) Distribution form to PMFS LLC before the end of the 30 day period constitutes a
waiver of my rights to any additional time for consideration of my options and authorizes the distribution of
my benefits or direct rollover, as elected, before the expiration of the 30 day period. Furthermore, I attest
that no more than 180 days has elapsed from the date I received the Special Tax Notice.
Under the 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, or 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 above if you are not a U.S. person (including a U.S. resident alien).
The IRS does not require your consent to any provisions of this document
other than certification required to avoid backup withholding.
X____________________________________________________
Participant’s, Beneficiary’s or Authorized signature
MF1005
Ed.10/2011
Page 8 of 12
___________________
Date
SPECIAL TAX NOTICE REGARDING SECTION 403(b)(7) TAX DEFERRED CUSTODIAL ACCOUNT PAYMENTS
INTERNAL REVENUE CODE SECTION 402(f) NOTICE
This notice is provided to you by Prudential Trust Company
(Custodian) and its affiliates as custodian of your Custodial
Account.
You are receiving this notice because all or a portion of a
payment you are receiving from your currently held internal
Revenue Code section 403(b) (7) tax-deferred custodial
account (Custodial Account), which satisfies the general
requirements of a section 403(b) tax deferred annuity (TDA),
is eligible to be rolled over to an IRA or an employer plan.
This notice is intended to help you decide whether to do
such a rollover.
This notice describes the rollover rules that apply to
payments from the Plan that are not from a designated Roth
account (a type of account with special tax rules in some
employer plans). If you also receive a payment from a
designated Roth account in the Plan, you will be provided a
different notice for that payment, and the Plan administrator
or the payor will tell you the amount that is being paid from
each account.
Rules that apply to most payments from a plan are described
in the “General Information About Rollovers” section.
Special rules that only apply in certain circumstances are
described in the “Special Rules and Options” section.
The Internal Revenue Code provides several complex rules
relating to the taxation of the amounts you receive in this
distribution. This notice merely summarizes these rules,
and the information contained herein has been taken from
a model notice prepared by the Internal Revenue Service
(IRS). Please note that the Custodian and its agents and
representatives assume no responsibility for the accuracy
of this model notice and cannot provide you with tax or
legal advice with respect to these issues. You should
promptly consult a tax adviser in deciding what course of
action to follow with respect to this distribution in your
particular circumstances.
If you have additional questions after reading this notice,
you can contact the Custodian of your Custodial Account at
(800) 225-1852.
GENERAL INFORMATION ABOUT ROLLOVERS
How can a rollover affect my taxes?
You will be taxed on a payment from the Plan if you do not
roll it over. If you are under age 59 ½ and do not do a
rollover, you will also have to pay a 10% additional income
tax on early distributions (unless an exception applies).
However, if you do a rollover, you will not have to pay tax
until you receive payments later and the 10% additional
Ed.10/2011
income tax will not apply if those payments are made after
you are age 59 ½ (or if an exception applies).
Where may I roll over the payment?
You may roll over the payment to either an IRA (a
individual retirement account or an individual retirement
annuity) or an employer plan (a tax-qualified plan, section
403(b) plan, or governmental section 457(b) plan that will
accept the rollover. The rules of the IRA or employer plan
that holds the rollover will determine your investment
options, fees, and rights to payment from the IRA or
employer plan (for example, no spousal consent rules
apply to IRAs and IRAs may not provide loans).Further, the
amount rolled over will become subject to the tax rules
that apply to the IRA or employer plan.
How do I do a rollover?
There are two ways to do a rollover. You can do either a
direct rollover or a 60-day rollover.
If you choose a direct rollover
The Plan will make the payment directly to your IRA or an
employer plan. You should contact the IRA sponsor or the
administrator of the employer plan for information on how
to do a direct rollover.
If you choose not to do a direct rollover
You may still do a rollover by making a deposit into an IRA
or eligible employer plan that will accept it. You will have
60 days after you receive the payment to make the
deposit. If you do not do a direct rollover, the Plan is
required to withhold 20% of the payment for federal
income taxes (up to the amount of cash and property
received other than employer stock). This means that, in
order to roll over the entire payment in a 60-day rollover,
you must use other funds to make up for the 20% withheld.
If you do not roll over the entire amount of the payment,
the portion not rolled over will be taxed and will be subject
to the 10% additional income tax on early distributions if
you are under age 59 ½ (unless an exception applies).
Your Right to Waive the 30-Day Notice Period
A distribution will not be made to you until 30 days after
you receive this Special Tax Notice. During the 30 days
following your receipt of this Special Tax Notice, you may
decide whether or not you want to elect a direct rollover.
However, by completing and returning the distribution
form, which includes the election to waive the 30-day
waiting period, within the 30 day period, you may waive
the 30-day waiting period. Your withdrawal will then be
processed in accordance with this election as soon as
practical after it is received by the Custodian.
Page 9 of 12
How much may I roll over?
If you wish to do a rollover, you may roll over all or part of
the amount eligible for rollover. Any payment from the
Plan is eligible for rollover, except:
• Certain payments spread over a period of at least 10
years or over your life or life expectancy (or the lives
or joint life expectancy of you and your beneficiary)
• Required minimum distributions after age 70 ½ (or after
death).
• Hardships distributions.
• Corrective distributions of contributions that exceed
tax law limitations.
• Contributions made under special automatic
enrollment rules that are withdrawn pursuant to your
request within 90 days of enrollment.
The plan administrator or the payor can tell you what
portion of a payment is eligible for rollover.
If I don’t do a rollover, will I have to pay the 10% additional
income tax on early distributions?
If you are under age 59 ½, you will have to pay the 10%
additional income tax on early distributions for any payment
from the Plan (including amounts withheld for income tax)
that you do not roll over, unless one of the exceptions listed
below applies. This tax is in addition to the regular income
tax on the payment not rolled over.
The 10% additional income tax does not apply to the
following payments from the Plan:
• Payments made after you separate from service if you
will be at least age 55 in the year of the separation.
• Payments that start after you separate from service if
paid at last annually in equal or close to equal
amounts over your life or life expectancy (or the lives
or joint life expectancy of you and your beneficiary).
• Corrective distributions of contributions that exceed
tax law limitations.
• Contributions made under special automatic enrollment
rules that are withdrawn pursuant to your request
within 90 days of enrollment
• Payments made directly to the government to satisfy a
federal tax levy.
• Payments made under a qualified domestic relations
order(QDRO).
• Payments up to the amount of your deductible medical
expenses.
Ed.10/2011
• Certain payments made while you are on active duty if
you were a member of a reserve component called to
duty after September 11, 2001 for more than 179 days.
• Payments of certain automatic enrollment contributions
requested to be withdrawn within 90 days of the first
contribution.
If I do a rollover to an IRA, will the 10% additional income
tax apply to early distributions from the IRA?
If you receive a payment from an IRA when you are under
age 59 ½, you will have to pay the 10% additional income tax
on early distributions from the IRA, unless an exception
applies. In general, the exceptions to the 10% additional
income tax for early distributions from an IRA are the same
as the exceptions listed above for early distributions from a
plan. However, there are a few differences for payments
from an IRA including:
• There is no exception for payments after separation
from service that are made after age 55.
• The exception for qualified domestic relations orders
(QDRO’s) does not apply (although a special rule
applies under which, as part of a divorce or
separation agreement, a tax-free transfer may be
made directly to an IRA of a spouse or former spouse).
• The exception for payments made at least annually in
equal amounts over a specified period applies without
regard to whether you have had a separation from
service.
• There are additional exceptions for (1) payments for
qualified higher education expenses, (2) payments up
to $10,000 used in a qualified first-time home purchase,
and (3) payments after you have received unemployment
compensation for 12 consecutive weeks (or would
have been eligible to receive unemployment
compensation but for self-employed status).
Will I owe State income taxes?
This notice does not describe any State or local income tax
rules (including withholding rules).
SPECIAL RULES AND OPTIONS
If your payment includes after tax contributions
After-tax contributions included in a payment are not taxed.
If a payment is only part of your benefit, an allocable portion
of your after-tax contributions is generally included in the
payment. If you have pre-1987 after-tax contributions
maintained in a separate account, a special rule may apply
to determine whether the after-tax contributions are
included in a payment.
Page 10 of 12
You may roll over to an IRA a payment that includes aftertax contributions through either a direct rollover or a 60 day
rollover. You must keep track of the aggregate amount of
the after-tax contributions in all of your IRAs (in order to
determine your taxable income for later payments from
the IRAs).
If you do a direct rollover of only a portion of the amount
paid from the Plan and a portion is paid to you, each of the
payments will include an allocable portion of the after-tax
contributions. If you do a 60-day rollover to an IRA of only
a portion of the payment made to you, the after-tax
contributions are treated as rolled over last. For example,
assume you are receiving a complete distribution of your
benefit which totals $12,000, of which $2000.00 is after tax
contributions. In this case, if you roll over $10,000 to an IRA
in a 60-day rollover, no amount is taxable because the
$2000.00 amount not rolled over is treated as being after-tax
contributions.
You may roll over to an employer plan all of a payment that
includes after-tax contributions, but only through a direct
rollover (and only if the receiving plan separately accounts
for after-tax contributions and is not a governmental
section 457(b) plan). You can do a 60-day rollover to an
employer plan of part of a payment that includes after-tax
Contributions, but only up to the amount of the payment that
would be taxable if not rolled over.
purpose, a public safety officer is a law enforcement
officer, firefighter, chaplain, or member of a rescue squad
or ambulance crew.
If you roll over your payment to a Roth IRA
If you roll over the payment to a Roth IRA, later payments
from the Roth IRA that are qualified distributions will not be
taxed (including earnings after the rollover). A qualified
distribution from a Roth IRA is a payment made after you are
age 59 ½ (or after your death or disability, or as a qualified
first-time homebuyer distribution of up to $10,000) and after
you have had a Roth IRA for at least 5 years. In applying this
5-year rule, you count from January 1 of the year for which
your first contribution was made to a Roth IRA. Payments
from the Roth IRA that are not qualified distributions will be
taxed to the extent of earnings after the rollover, including
the10% additional income tax on early distributions (unless
an exception applies). You do not have to take required
minimum distributions from a Roth IRA during your lifetime.
For more information, see IRS Publication 590, Individual
Retirement Arrangements (IRAs).
For Payments from the Plan during 2010 that are rolled over
to a Roth IRA in 2010, the taxable amount can be spread
over a 2-year period starting in 2011.
If your employer’s plan allows, effective September 27,
2010, you can roll over a payment from the Plan to a
designated Roth account in the employer plan.
If you miss the 60-day rollover deadline
Generally, the 60-day rollover deadline cannot be extended.
However, the IRS has limited authority to waive the
deadline under certain extraordinary circumstances such
as when external events prevented you from completing
the rollover by the 60-day rollover deadline. To apply for a
waiver, you must file a private letter ruling request with the
IRS. Private letter ruling requests require the payment of a
nonrefundable user fee. For more information, see IRS
Publication 590, Individual Arrangements (IRAs).
If you are an eligible retired public safety officer and your
pension payment is used to pay for health coverage or
qualified long-term care insurance.
If the Plan is a governmental plan, you retired as a public
safety officer, and your retirement was by reason of
disability or was after normal retirement age, you can
exclude from your taxable income plan payments paid
directly as premiums to an accident or health plan (or a
qualified long-term care insurance contract) that your
employer maintains for you, your spouse, or your
dependents, up to a maximum of $3000.00 annually. For this
Ed.10/2011
IF YOU ARE NOT A 403(b) PLAN PARTICIPANT
(surviving spouse, alternate payees,
and other beneficiaries)
Payments after death of the participant
If you receive a distribution after the participant’s death that
you do not roll over, the distribution will generally be taxed
in the same manner described elsewhere in this notice.
However, the 10% additional income tax on early
distributions and the special rules for public safety officers
do not apply, and the special rule described under the
section “If you were born on or before January 1, 1936”
applies only if the participant was born on or before
January 1, 1936.
If you are a surviving spouse
If you receive a payment from the Plan as the surviving
spouse of a deceased participant, you have the same
rollover options that the participant would have had, as
described elsewhere in this notice. In addition, if you
choose to do a rollover to an IRA, you may treat the IRA as
your own or as an inherited IRA.
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An IRA you treat as your own is treated like any other IRA
of yours, so that payments made to you before you are age
59 ½ will be subject to the 10% additional income tax on
early distributions (unless an exception applies) and
required minimum distributions from your IRA do not have
to start until after you are age 70 ½.
If you treat the IRA as an inherited IRA, payments from the
IRA will not be subject to the 10% additional income tax on
early distributions. However, if the participant had started
taking required minimum distributions, you will have to
receive required minimum distributions from the inherited
IRA. If the participant had not started taking required
minimum distributions from the Plan, you will not have to
start receiving required minimum distributions from the
inherited IRA until the year the participant would have been
age 70 ½.
• If you are a surviving beneficiary other than a spouse
If you receive a payment from the Plan because of the
participant’s death and you are a designated
beneficiary other than a surviving spouse, the only
rollover option you have is to do a direct rollover to an
inherited IRA. Payments from the inherited IRA will
not be subject to the 10% additional income tax on
early distributions. You will have to receive required
minimum distributions from the inherited IRA.
Payments under a qualified domestic relations order
If you are the spouse or former spouse of the participant
who receives a payment from the Plan under a qualified
domestic relations order (QDRO), you generally have
the same options the participant would have (for example,
you may roll over the payment to your own IRA or an eligible
employer plan that will accept it). Payments under the
QDRO will not be subject to the 10% additional income tax
on early distributions.
If you are a nonresident alien
If you are a nonresident alien and you do not do a direct
rollover to a U.S. IRA or U.S. employer plan, instead of
withholding 20%, the Plan is generally required to withhold
30% of the payment for federal income taxes. If the amount
withheld exceeds the amount of tax you owe (as may
happen if you do a 60-day rollover), you may request an
income tax refund by filing form 1040NR and attaching your
Form 1042-S. See Form W-8BEN for claiming that you are
entitled to a reduced rate of withholding under an income
tax treaty. For more information, see also IRS Publication
519, U.S. Tax Guide for Aliens, and IRS Publication 515,
Withholding of Tax on Nonresident Aliens and Foreign
Entities.
Ed.10/2011
Other special rules
If a payment is one in a series of payments for less than 10
years, your choice whether to make a direct rollover will
apply to all later payments in the series (unless you make a
different choice for late payments).
If your payments for the year are less than $200 (not
including payments from a designated Roth account in the
Plan), the Plan is not required to allow you to do a direct
rollover and is not required to withhold for federal income
taxes. However, you may do a 60-day rollover.
Unless you elect otherwise, a mandatory cashout of more
than $1000 (not including payments from a designated Roth
account in the Plan) will be directly rolled over to an IRA
chosen by the Plan administrator or the payor. A mandatory
cashout is a payment from a plan to a participant made
before age 62 (or normal retirement age, if later) and
without consent, where the participant’s benefit does not
exceed $5000 (not including any amounts held under the
plan as a result of a prior rollover made to the plan).
You may have special rollover rights if you recently served
in the U.S. Armed Forces. For more information, see IRS
Publication 3 Armed Forces’ Tax Guide.
Please note that if you expatriate from the U.S., you may be
subject to special rules, and should consult with your
personal tax advisor to determine if you are required to
provide Prudential with IRS Form W-8CE.
For more information
You may wish to consult with the Plan administrator or
payor, or a professional tax advisor, before taking a
payment from the Plan. Also, you can find more detailed
information on the federal tax treatment of payments from
employer plans in: IRS Publication 575, Pension and
Annuity Income; IRS Publication 590, Individual Retirement
Arrangements (IRAs); and IRS Publication 571, TaxSheltered Annuity Plans (403(b) Plans). These publications
are available from a local IRS office, on the web at
www.irs.gov, or by calling 1-800-TAX-FORM.
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