Form Comb 84800s - Pruco Life Insurance Company - Request For Change Short Form printable pdf download

Request for Change

Short Form

The Prudential Insurance Company of America

Pruco Life Insurance Company of New Jersey

Pruco Life Insurance Company

All are Prudential Financial companies.

1. Identification Information

Policy number

Insured's full name

Mailing address*

*If this address is different than the address we have on our records,

we will change it unless you check here.

2. Signature and Tax Certification Section

This section is to be completed by the owner.

1. Owner's date of birth

2. You must indicate if you are not a U.S. citizen or resident alien. In that case, you must state the country of which you are a citizen and submit

the applicable IRS Form W-8(BEN, ECI, EXP, IMY). In most situations, the IRS Form W-8BEN, will be the appropriate IRS Form W-8.

Check one:

I am a U.S. Citizen or resident alien.

I am a Citizen of

Attach the applicable IRS Form W-8(BEN, ECI, EXP, IMY).

Under penalties of perjury, I (as policyowner) certify that:

3. My taxpayer identification number (TIN) is ________________________. If joint owners, second owner's TIN:______________________

(For individuals, the taxpayer identification number (TIN) is the Social Security number.)

4. Check one:

I am not subject to backup withholding because I have not been notified that I am subject to backup withholding as

a result of a failure to report all interest or dividends, or the IRS has notified me that I am no longer subject to

backup withholding.

I am subject to backup withholding.

By signing below; I:

agree to the request(s) made on this form.

understand that there may be tax implications on the request(s).

certify to the tax certification information completed above.

The Internal Revenue Service does not require your consent to any provision of this document other than the certification required

X Insured

X Owner (if different than Insured)

X Owner

X Joint owner (if different than Insured)

X Collateral assignee, if any

X Trust, if any

X Power of Attorney, if any

X Corporation, if any

Title

X Partnership, if any

Title

Signed at:

(City/State)

(Month/Day/Year)

For corporations, an authorized officer must sign. Be sure to include the title of the officer.

If president - no additional requirements

If vice president - for policies over $1,000,000, provide a Corporate Secretary's statement reflecting

the vice president's authority to sign

If any other officer - provide a corporate resolution

For partnerships with at least two general partners, two authorized general partners must sign with the title "general partner" after each

name (if only one, use "sole general partner") and include the name of the partnership.

For sole proprietorships, submit the signature of the owner, followed by "doing business as (company name), a sole proprietorship."

For trusts, each trustee must sign unless the trust itself or state law provides otherwise. Trustee must include trustee designation (for

example, "John Doe, Trustee under Trust Agreement dated 1/1/1998").

A holder of power of attorney must provide a copy of the power of attorney and include, following his or her signature, the words

"Attorney-in-fact for (owner's name)."

For a policy containing a limitation of rights, the person or entity in whose favor the rights have been limited must also sign.

3. Reference Information Representative must complete.

Representative's name

Contract number

Ed. 11/2006

COMB 84800S

Form Comb 84800s - Pruco Life Insurance Company - Request For Change Short Form

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