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Electronic Funds Transfer (EFT) Form
Annuities are issued by The Prudential Insurance Company of America (PICA), Pruco Life Insurance Company (in New York, by Pruco Life Insurance Company of
New Jersey), located in Newark, NJ (main ofce), or by Prudential Annuities Life Assurance Corporation, located in Shelton, CT. (main ofce), these entities are
referred to as “Prudential” below. All are Prudential Financial, Inc. companies and each is solely responsible for its own nancial condition and contractual
obligations. The Rock Prudential Logo is a registered service mark of PICA and its afliates.
1. OWNERSHIP INFORMATION
2. PAYMENT INSTRUCTIONS (Direct Deposit (ACH) to a Bank)
3. SIGNATURES
ORD 78278 Ed.1/18
Instructions: Sections 1, 2, and 3 must be completed, with signature(s) of contract owner(s) and all parties-in-interest in Section 3.
Please use a separate request form for each annuity contract.
Annuity Number
Owner Telephone Number
Owner Name (First, Middle, Last Name)
Joint Owner Name (If applicable)
If we require additional information to complete this request, please indicate who Prudential should contact:
Owner Financial Professional
• Voided check must show Name on account, current address,
routing and account numbers.
• Bank letter must be on bank letterhead, signed and dated by
bank representative and contain name on account, routing
and account numbers.
• If all required information is not provided, we will process
your request as a check and send to the owner’s address of
record.
Please indicate the type of disbursement for which this form will be used:
Future Annuity Payments Systematic Withdrawal
Required Minimum Distribution 72(t)/72(q) (Substantially Equal Payment Program)
Please allow 1-3 business days from the processing date to receive the funds in your bank account.
Funds must be sent to an account in the name of the contract owner. Requests for third party EFT (EFT to a party that is not the
contract owner) are not permitted.
Checkhereifyouraccountisalreadyonle.ProceedtotheSignaturesection.
If new account or changes to existing account: Checking - (A voided check or bank letter must be included with this request.)
Savings-(A letter from your bank is needed to have funds deposited to your savings account if a
deposit slip is not provided. Please see bank letter requirements below.)
Routing Number (9 digits) Bank Account Number
By signing below, I (we) authorize Prudential to initiate credit entries and if necessary, adjustments for any credit entries made in error to my (our) account
as indicated above. I (we) also direct the bank named above to credit and/ or debit the same to such account. This authorization will remain in effect until
further written notice from me (us) is received and processed by the Prudential Annuity Service Center. I understand that Prudential is relying on the infor-
mation that I (we) have provided on this form, and further understand that Prudential will not be liable for any losses or charges due to incorrect, outdated,
or incomplete information that has been provided on this form.
Annuities Service Center
1-888-778-2888
8:00AM–7:00PM ET, Monday–Thursday
8:00AM–6:00PM ET, Friday
Fax: (800) 576-1217
www.prudentialannuities.com
Regular Mail Delivery
AnnuitiesServiceCenter
P.O. Box 7960
Philadelphia, PA 19176
Overnight Service, Certified or
Registered Mail Delivery
PrudentialAnnuitiesServiceCenter
2101 Welsh Road
Dresher, PA 19025
OwnerSignatureDateofSignature(mm/dd/yyyy)
JointOwnerSignature (if applicable) DateofSignature(mm/dd/yyyy)
Party-In-InterestSignature (if any) DateofSignature(mm/dd/yyyy)
SIGN HERE
SIGN HERE
SIGN HERE
