STRATEGIC PARTNERS SELECT APPLICATION
Published on
[PRUDENTIAL LOGO] Exhibit 4(a)
Pruco Life Insurance Company of New Jersey, STRATEGIC PARTNERS SELECT(SM)
a Prudential company VARIABLE ANNUITY APPLICATION
Flexible Payment Variable
Deferred Annuity
- --------------------------------------------------------------------------------
[?] On these pages, I, you, and your refer to the contract owner.
We, us, and our refer to Pruco Life Insurance Company of New
Jersey, a Prudential company.
- --------------------------------------------------------------------------------
[1] CONTRACT Contract number (if any) 123456789
OWNER
INFORMATION [X] Individual [ ] Corporation [ ] UGMA/UTMA [ ] Other
TRUST: [ ] Grantor [ ] Revocable [ ] Irrevocable
TRUST DATE (mo., day, year)
-- -- ----
Name of owner (first, middle initial, last name)
John Doe
---------------------------------------------------------------
Street Apt.
123 Main Street
--------------------------------------------- ---------------
City State ZIP code
ANYTOWN NJ 07101-0000
------------------------- --- -----------------
Social Security number/TIN
123456789
------------------------------
Date of birth (mo., day, year)
04251948
------------------------------
Telephone number
888 555-5555
------------------------------
[ ] Female [x] U.S. citizen
[X] Male [ ] Resident alien
[ ] I am not a U.S. citizen or resident alien. I am a citizen
of:
-----------------------------------------------------------
If a corporation or trust is indicated above, please check the
following as it applies.
[ ] Tax-exempt entity under IRS Code 501
[ ] Trust acting as agent for an individual under IRS
Code 72(u)
- --------------------------------------------------------------------------------
[2] JOINT Name of joint owner (first, middle initial, last name)
OWNER Mary Doe
INFORMATION ---------------------------------------------------------------
(if any)
Do not Street (Leave address blank if same as owner.)
complete if
you are ---------------------------------------------------------------
opening
an IRA. City State ZIP code
------------------------- --- -----------------
Social Security number/TIN
987654321
------------------------------
Date of birth (mo., day, year)
05141950
------------------------------
Telephone number
888 555-5555
------------------------------
[X] Female [X] U.S. citizen
[ ] Male [ ] Resident alien
[ ] I am not a U.S. citizen or resident alien. I am a citizen
of:
-----------------------------------------------------------
- --------------------------------------------------------------------------------
[3] ANNUITANT This section must be completed only if the annuitant is not the
INFORMATION owner or if the owner is a trust or a corporation.
(if
different Name of annuitant (first, middle initial, last name)
than the
owner) ---------------------------------------------------------------
Street (Leave address blank if same as owner.) Apt.
--------------------------------------------- ---------------
City State ZIP code
------------------------- --- -----------------
Social Security number/TIN
------------------------------
Date of birth (mo., day, year)
------------------------------
Telephone number
------------------------------
[ ] Female [ ] U.S. citizen
[ ] Male [ ] Resident alien
[ ] I am not a U.S. citizen or resident alien. I am a citizen
of:
-----------------------------------------------------------
- --------------------------------------------------------------------------------
PRUCO CORPORATE OFFICE: Pruco Life Insurance Company of New Jersey, Newark,
NJ 07102
[ORD 99669 NEW YORK] Page 1 of 6 Ed. 5/2001
- --------------------------------------------------------------------------------
|1| CO-ANNUITANT Name of co-annuitant (first, middle initial, last name)
INFORMATION
(if any)
Do not |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
complete if Social Security number/TIN Date of birth (mo., day, year)
you are |_|_|_|_|_|_|_|_|_| |_|_| |_|_| |_|_|_|_|
opening Telephone number
an IRA. |_|_|_| |_|_|_|-|_|_|_|_|
[ ] Female [ ] U.S. citizen
[ ] Male [ ] Resident alien
[ ] I am not a U.S. citizen or resident alien. I am a citizen of
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
- --------------------------------------------------------------------------------
|2| BENEFICIARY [X] PRIMARY CLASS
INFORMATION Name of beneficiary (first, middle initial, last name)
(Please add If trust, include name of trust and trustee's name.
additional |M|A|R|Y|_|D|O|E|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
benefi- TRUST: [ ] Revocable [ ]Irrevocable
ciaries in Trust date (mo., day, year) |_|_| |_|_| |_|_|_|_|
section 15.)
Beneficiary's relationship to annuitant
|S|P|O|U|S|E|_|_|_|_|_|_|_|_|_|
CHECK ONLY ONE: [ ] Primary class [ ] Secondary class
Name of beneficiary (first, middle initial, last name)
If trust, include name of trust and trustee's name.
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
TRUST: [ ] Revocable [ ] Irrevocable
Trust date (mo., day, year) |_|_| |_|_| |_|_|_|_|
Beneficiary's relationship to annuitant
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
- --------------------------------------------------------------------------------
|3| TYPE OF PLAN TYPE. Check only one:
PLAN AND
SOURCE [X] Non-qualified [ ] Traditional IRA
OF -------------------------------------------------------------------
FUNDS
(minimum SOURCE OF FUNDS. Check all that apply:
of
$10,000) [X] Total amount of the check(s) included with this
application. (Make checks payable to Prudential.)
$|_|_|, |_|1|0|, |0|0|0|.|0|0|
[ ] IRA Rollover
$|_|_|, |_|_|_|, |_|_|_|, _|_|_|
If Traditional IRA, new contribution(s) for the current and/or
previous year, complete the following:
$|_|_|, |_|_|_|.|_|_| Year |_|_|_|_|
$|_|_|, |_|_|_|.|_|_| Year |_|_|_|_|
[ ] 1035 Exchange (non-qualified only), estimated amount:
$|_|_|, |_|_|_|,|_|_|_|.|_|_|
[ ] IRA Transfer (qualified), estimated amount:
$|_|_|, |_|_|_|,|_|_|_|.|_|_|
[ ] Direct Rollover (qualified), estimated amount:
$|_|_|, |_|_|_|,|_|_|_|.|_|_|
- --------------------------------------------------------------------------------
[ORD 99669 NEW YORK] Page 2 of 6 Ed. 5/2001
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/7/ PURCHASE Please write in the percentage of your payment that you want
PAYMENT to allocate to the following options. The total must equal
ALLOCATION(S) 100 percent. IF CHANGES ARE MADE TO THE ALLOCATIONS LISTED
BELOW, THE APPLICANT MUST INITIAL THE CHANGES.
- --------------------------------------------------------------------------------
/8/ DOLLAR COST / / DOLLAR COST AVERAGING: I authorize Prudential to
AVERAGING automatically transfer funds as indicated below:
PROGRAM
TRANSFER FROM: (You cannot transfer from the 7 Year Market
Value Adjustment Option.)
Option Code: $ , , . or %
TRANSFER FREQUENCY: / / Annually / / Semiannually
/ / Quarterly / / Monthly
TRANSFER TO: (You cannot transfer to the Interest Rate
Options.) The total of the two columns must
equal 100 percent.
OPTION CODE PERCENT OPTION CODE PERCENT
% %
% %
% %
I understand that the transfer will continue until: (1) I terminate the
program; (2) the funds in the account from which money is being transferred are
exhausted; or (3) the funds in the account fall below the required minimum. I
also understand that the Dollar Cost Averaging (DCA) programs are described in
and subject to the rules and restrictions contained in the prospectus.
- --------------------------------------------------------------------------------
- -------------------- Page 3 of 6 ed. 5/2001
ORD 99669 New York
- --------------------
________________________________________________________________________________
9 AUTO- [ ] AUTO-REBALANCING: I want to maintain my allocation
REBALANCING percentages. Please have my portfolio mix
automatically adjusted as allocated in section 7
under my variable investment options.
Adjust my portfolio: [ ] Annually [ ] Semiannually
[ ] Quarterly [ ] Monthly
Please specify the start date if different than the
contract date: ---------
month day year
________________________________________________________________________________
10 AUTOMATED [ ] AUTOMATED WITHDRAWAL: I would like to elect automatic
WITHDRAWALS withdrawals from my annuity contract.
Automated withdrawals can be made monthly, quarterly,
semiannually, or annually. The amount of each
withdrawal must be at least $100. You must complete
the Request for Partial or Automated Withdrawal form
(ORD 78276) in order to specify start date,
frequency, and amount of withdrawals.
NOTE: AUTOMATIC WITHDRAWALS CANNOT BE USED TO
CONTINUE THE CONTRACT BEYOND THE MATURITY DATE. ON
THE MATURITY DATE THE CONTRACT MUST ANNUITIZE.
________________________________________________________________________________
11 AGGREGATION [ ] I have purchased another non-qualified annuity from
(non-qualified Prudential or an affiliated company this calendar
annuities only) year.
Contract number -----------------
________________________________________________________________________________
12 REPLACEMENT THIS SECTION MUST BE COMPLETED.
(Please enter
additional Will the proposed annuity contract replace any existing
comments in insurance policy(ies) or annuity contract(s)?
section 15.) [ ] Yes [X] No
If "Yes," provide the following information for each
policy or contract and attach all applicable Prudential
disclosure and state replacement forms.
Company name --------------------------------------------
Policy or contract number Year of issue (mo, day, year)
------------------------- -----------------------------
Name of plan (if applicable)
----------------------------
THIS QUESTION MUST BE COMPLETED BY THE REPRESENTATIVE.
Do you have, from any source, facts that any person
named as the owner or joint owner above is replacing or
changing any current insurance or annuity in any
company?
[ ] Yes [X] No
________________________________________________________________________________
13 SIGNATURE(S) If applying for an IRA, I acknowledge receiving an IRA
disclosure statement and understand that I will be given
a financial disclosure statement with the contract. I
understand that tax deferral is provided by the IRA, and
acknowledge that I am purchasing this contract for its
features other than tax deferral, including the lifetime
income payout option, the Death Benefit protection, the
ability to transfer among investment options without
sales or withdrawal charges, and other features as
described in the prospectus.
No representative can make or change a contract or waive
any of the rights.
I believe that this contract meets my needs and financial
objectives. Furthermore, I (1) understand that any amount
of purchase payments allocated to a variable investment
option will reflect the investment experience of that
option and, therefore, annuity payments and surrender
values may vary and are not guaranteed as to a fixed
dollar amount, and (2) acknowledge receipt of the current
prospectus for this contract and the variable investment
options.
(continued)
________________________________________________________________________________
ORD 99669 New York Page 4 of 6 Ed. 5/2001
SIGNATURE(S) [ ] If this contract has a joint owner, please check this box to
(continued) authorize Prudential to act on the instruction(s) of either
the owner or joint owner with regard to transactions under
the contract.
[ ] If this application is being signed at the time the contract
is delivered, I acknowledge receipt of the contract.
[ ] Check here to request a Statement of Additional Information.
MINIMUM DISTRIBUTION UNDER AN IRA: IF YOU HAVE NOT MET THE
REQUIRED MINIMUM DISTRIBUTION FOR THE YEAR IN WHICH THE FUNDS ARE
PAID TO PRUDENTIAL:
I understand it is my responsibility to remove the minimum
distribution from the purchase payment prior to sending money to
Prudential with this application. Unless we are notified
otherwise, Prudential will assume that the owner is satisfied with
the required minimum distributions from other IRA funds.
By signing this form, the trustee(s)/officer(s) hereby represents
that the trustee(s)/officer(s) possess(es) the authority, on
behalf of the non-natural person, to purchase the annuity contract
and to exercise all rights of ownership and control over the
contract, including the right to make purchase payments to the
contract.
I understand that any amount of purchase payments allocated to the
MVA option may increase or decrease due to such adjustment prior
to the maturity of the interest cell.
OWNER'S TAX CERTIFICATION
------------------------------------------------------------------
Under penalty of perjury, I certify that the taxpayer
identification number (TIN) I have listed on this form is my
correct taxpayer identification number, I HAVE/HAVE NOT (circle
one) been notified by the Internal Revenue Service that I am
subject to backup withholding due to underreporting of interest or
dividends.
------------------------------------------------------------------
THE INTERNAL REVENUE SERVICE DOES NOT REQUIRE YOUR
CONSENT TO ANY PROVISION OF THIS DOCUMENT
OTHER THAN THE CERTIFICATIONS REQUIRED
TO AVOID BACKUP WITHHOLDING.
------------------------------------------------------------------
We must have both the owner's and annuitant's signatures even if
this contract is owned by a trust, corporation, or other entity.
If the annuitant is a minor, please provide the signature of a
legal guardian or custodian.
I hereby certify that all the information contained in this
application is complete and true to the best of my knowledge.
X /s/ John Doe 05 04 2001
--------------------------------------- -- -- ----
Contract owner's signature and date month day year
X /s/ Mary Doe 05 04 2001
--------------------------------------- -- -- ----
Joint owner's signature (if applicable) month day year
and date
X /s/ John Doe 05 04 2001
--------------------------------------- -- -- ----
Annuitant's signature (if applicable) month day year
and date
X
--------------------------------------- -- -- ----
Co-annuitant's signature (if applicable) month day year
and date
/s/ Anytown, N.J.
---------------------------------------
Signed at (city, state)
- --------------------------------------------------------------------------------
ORD 99669 New York Page 5 of 6 Ed. 5/2001
================================================================================
14 REPRESEN- Commission Option (For Retail Distribution only. Choose only
TATIVE'S one.):
SIGNATURE(S)
1. [ ] No Trail 2. [ ] Mid Trail 3. [ ] High Trail
Note: If an option is not selected, the default option will be
Option 3.
This application is submitted in the belief that the purchase of
this contract is appropriate for the applicant based on the
information provided and as reviewed with the applicant.
Reasonable inquiry has been made of the owner concerning the
owner's overall financial situation, needs, and investment
objectives.
The representative hereby certifies that all information
contained in this application is true to the best of his or her
knowledge.
/s/ Richard Roe 123456789
------------------------------------------- ----------------
Representative's name (Please print) Rep's contract/
FA number
X /s/ Richard Roe 05 04 2001
------------------------------------------- ----------------
Representative's signature and date month day year
------------------------------------------- ----------------
Second representative's name (Please print) Rep's contract/
FA number
X
------------------------------------------- ---------------
Second representative's signature and date month day year
/s/ Sunnytown - SNTN 888 555-5555
------------------------------------------- ----------------
Branch/field office name and code Representative's
telephone number
================================================================================
15 ADDITIONAL
REMARKS
------------------------------------------------------------------
------------------------------------------------------------------
------------------------------------------------------------------
------------------------------------------------------------------
------------------------------------------------------------------
------------------------------------------------------------------
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================================================================================
STANDARD PRUDENTIAL ANNUITY SERVICE CENTER
MAIL TO: PO BOX 7590
PHILADELPHIA, PA 19101
OVERNIGHT PRUDENTIAL ANNUITY SERVICE CENTER
MAIL TO: 2101 WELSH ROAD
DRESHER, PA 19025
If you have any questions, please call the Prudential Annuity
Service Center at (888) 778-2888, Monday through Friday between
8:00 a.m. and 8:00 p.m. Eastern time.
================================================================================
ORD 99669 New York Page 6 of 6 Ed. 5/2001
[PRUDENTIAL LOGO] PRUDENTIAL STRATEGIC PARTNERS SELECT(SM)
Pruco Life Insurance VARIABLE ANNUITY APPLICATION
Company of New Jersey, Flexible Payment Variable
a Prudential company Deferred Annuity
- --------------------------------------------------------------------------------
On these pages, I, you, and your refer to the contract owner.
We, us, and our refer to Pruco Life Insurance Company of New
Jersey, a Prudential company.
- --------------------------------------------------------------------------------
1 CONTRACT Contract number (if any) 123456789
OWNER [X] Individual [ ] Corporation [ ] UGMA/UTMA [ ] Other
INFORMATION TRUST: [ ] Grantor [ ] Revocable [ ] Irrevocable
TRUST DATE (mo., day, year)
--------------------
Name of owner (first, middle initial, last name)
JOHN DOE
-------------------------------------------------------------
Street Apt.
123 MAIN STREET
-------------------------------------------------------------
City State ZIP code
ANYTOWN NY 07101-0000
------------ --------- --------------
Social Security number/TIN Date of birth (mo., day, year)
123456789 04 25 1948
-------------------------- --------------------------------
Telephone number
888 555-5555
--------------------------
[ ] Female [X] U.S. citizen [ ] I am not a U.S.
[X] Male [ ] Resident alien citizen or resident
alien. I am a citizen
of
----------------------
If a corporation or trust is indicated above, please check
the following as it applies.
[ ] Tax-exempt entity under IRS Code 501
[ ] Trust acting as agent for an individual under IRS
Code 72(u)
- --------------------------------------------------------------------------------
2 JOINT Name of joint owner (first, middle initial, last name)
OWNER MARY DOE
INFORMATION -------------------------------------------------------------
(if any)
Do not Street (Leave address blank if same as owner.) Apt.
complete if
you are -------------------------------------------------------------
opening
an IRA. City State ZIP code
------------ --------- --------------
Social Security number/TIN Date of birth (mo., day, year)
987654321 05 17 1950
-------------------------- --------------------------------
Telephone number
888 555-5555
--------------------------
[X] Female [X] U.S. citizen [ ] I am not a U.S.
[ ] Male [ ] Resident alien citizen or resident
alien. I am a citizen
of
----------------------
- --------------------------------------------------------------------------------
3 ANNUITANT This section must be completed only if the annuitant is not
INFORMATION the owner or if the owner is a trust or a corporation.
(if different
than the Name of annuitant (first, middle initial, last name)
owner)
-------------------------------------------------------------
Street (Leave address blank if same as owner.) Apt.
-------------------------------------------------------------
City State ZIP code
------------ --------- --------------
Social Security number/TIN Date of birth (mo., day, year)
-------------------------- --------------------------------
Telephone number
--------------------------
[ ] Female [ ] U.S. citizen [ ] I am not a U.S.
[ ] Male [ ] Resident alien citizen or resident
alien. I am a citizen
of
----------------------
- --------------------------------------------------------------------------------
Pruco Corporate Office: Pruco Life Insurance Company of New Jersey,
Newark NJ 07102
ORD 99669 New York - Third Party Page 1 of 6 Ed. 5/2001 Third Party
- --------------------------------------------------------------------------------
/4/ CO-ANNUITANT Name of co-annuitant (first, middle initial, last name)
INFORMATION
(if any) ------------------------------------------------------------
Do not
complete if Social Security number/TIN Date of birth (mo., day, year)
you are
opening an -------------------------- -- -- ----
IRA. Telephone Number
--- --------
/ / Female / / U.S. citizen
/ / Male / / Resident alien
/ / I am not a U.S. citizen or resident alien.
I am a citizen of
--------------------------------------------------------
- --------------------------------------------------------------------------------
/5/ BENEFICIARY /X/ PRIMARY CLASS
INFORMATION Name of beneficiary (first, middle initial, last name).
(Please add If trust, include name of trust and trustee's name.
additional Mary Doe
beneficiaries ------------------------------------------------------------
in section 15.) TRUST: / / Revocable / / Irrevocable
Trust date (mo., day, year)
-- -- ----
Beneficiary's relationship to annuitant SPOUSE
--------------------
CHECK ONLY ONE: / / Primary class / / Secondary class
Name of beneficiary (first, middle initial, last name).
If trust, include name of trust and trustee's name.
------------------------------------------------------------
TRUST: / / Revocable / / Irrevocable
Trust date (mo., day, year)
-- -- ----
Beneficiary's relationship to annuitant
--------------------
- --------------------------------------------------------------------------------
/6/ TYPE OF PLAN PLAN TYPE. Check only one:
AND SOURCE OF /X/ Non-qualified / / Traditional IRA
FUNDS
(minimum of ------------------------------------------------------------
$10,000)
SOURCE OF FUNDS. Check all that apply:
/X/ Total amount of the check(s) included with this
application. (Make checks payable to
Prudential.) $ 10,000.00
-- ,--- --- --
/ / IRA Rollover $ , , .
-- --- --- --
If Traditional IRA, new contribution(s) for the current
and/or previous year, complete the following:
$ , . Year $ , . Year
- --- -- ---- - --- -- ----
/ / 1035 Exchange (non-qualified only),
estimated amount: $ , , .
-- --- --- --
/ / IRA Transfer (qualified),
estimated amount: $ , , .
-- --- --- --
/ / Direct Rollover (qualified),
estimated amount: $ , , .
-- --- --- --
- --------------------------------------------------------------------------------
- ---------------------------------- Page 2 of 6 Ed. 5/2001 Third Party
ORD 99669 New York - Third Party
- ----------------------------------
________________________________________________________________________________
7 PURCHASE Please write in the percentage of your payment that you
PAYMENT want to allocate to the following options. The total must
ALLOCATION(S) equal 100 percent. IF CHANGES ARE MADE TO THE ALLOCATIONS
LISTED BELOW, THE APPLICANT MUST INITIAL THE CHANGES.
________________________________________________________________________________
8 DOLLAR COST [ ] DOLLAR COST AVERAGING: I authorize Prudential to
AVERAGING automatically transfer funds as indicated below.
PROGRAM TRANSFER FROM: (You cannot transfer from the 7 Year
Market Value Adjustment Option.)
Option code: ------ $--,---,---.-- or ----%
TRANSFER FREQUENCY: [ ] Annually [ ] Semiannually
[ ] Quarterly [ ] Monthly
TRANSFER TO: (You cannot transfer to the Interest Rate
Options.)
The total of the two columns must equal 100 percent.
I understand that the transfer will continue until: (1) I
terminate the program; (2) the funds in the account from
which money is being transferred are exhausted; or (3) the
funds in the account fall below the required minimum. I
also understand that the Dollar Cost Averaging (DCA)
programs are described in and subject to the rules and
restrictions contained in the prospectus.
________________________________________________________________________________
ORD 99669 NEW YORK - THIRD PARTY Page 3 of 6 Ed. 5/2001 Third Party
________________________________________________________________________________
9 AUTO- / / AUTO-REBALANCING: I want to maintain my allocation percentages.
REBALANCING Please have my portfolio mix automatically adjusted as
allocated in section 7 under my variable investment options.
Adjust my portfolio: / / Annually / / Semiannually / / Quarterly / / Monthly
Please specify the start date if different than the contract date:
-- -- ----
month day year
________________________________________________________________________________
10 AUTOMATED / / AUTOMATED WITHDRAWAL: I would like to elect automatic
WITHDRAWALS withdrawals from my annuity contract.
Automated withdrawals can be made monthly, quarterly,
semiannually, or annually. The amount of each withdrawal
must be at least $100. You must complete the Request for
Partial or Automated Withdrawal form (P-ORD 78276) in order
to specify start date, frequency, and amount of withdrawals.
NOTE: AUTOMATIC WITHDRAWALS CANNOT BE USED TO CONTINUE THE
CONTRACT BEYOND THE MATURITY DATE. ON THE MATURITY DATE THE
CONTRACT MUST ANNUITIZE.
________________________________________________________________________________
11 AGGREGATION / / I have purchased another non-qualified annuity from
(non-qualified Prudential or an affiliated company this calendar year.
annuities only)
Contract number
---------
________________________________________________________________________________
12 REPLACEMENT THIS SECTION MUST BE COMPLETED.
(Please enter
additional Will the proposed annuity contract replace any existing
comments in insurance policy(ies) or annuity contract(s)?
section 15.)
/ / Yes /X/ No
If "Yes," provide the following information for each policy
or contract and attach all applicable Prudential disclosure
and state replacement forms.
Company name
-----------------------------------------------------------
Policy or contract number Year of issue Name of plan (if applicable)
(mo., day, year)
- ---------------------- -- -- ---- -------------------------
THIS QUESTION MUST BE COMPLETED BY THE FINANCIAL
PROFESSIONAL.
Do you have, from any source, facts that any person named as
the owner or joint owner above is replacing or changing any
current insurance or annuity in any company?
/ / Yes /X/ No
________________________________________________________________________________
13 SIGNATURES If applying for an IRA, I acknowledge receiving an IRA
disclosure statement and understand that I will be given a
financial disclosure statement with the contract. I
understand that tax deferral is provided by the IRA, and
acknowledge that I am purchasing this contract for its
features other than tax deferral, including the lifetime
income payout option, the Death Benefit protection, the
ability to transfer among investment options without sales
or withdrawal charges, and other features as described in
the prospectus.
No representative can make or change a contract or waive any
of the rights.
I believe that this contract meets my needs and financial
objectives. Furthermore, I (1) understand that any amount of
purchase payments allocated to a variable investment option
will reflect the investment experience of that option and,
therefore, annuity payments and surrender values may vary
and are not guaranteed as to a fixed dollar amount, and (2)
acknowledge receipt of the current prospectus for this
contract and the variable investment options.
(continued)
________________________________________________________________________________
ORD 99669 New York - Third Party Page 4 of 6 Ed. 5/2001 Third Party
13
SIGNATURE(S) [ ] If this contract has a joint owner, please check this box to
(continued) authorize Prudential to act on the instruction(s) of either
the owner or joint owner with regard to transactions under
the contract.
[ ] If this application is being signed at the time the contract
is delivered, I acknowledge receipt of the contract.
[ ] Check here to request a Statement of Additional Information.
MINIMUM DISTRIBUTION UNDER AN IRA: IF YOU HAVE NOT MET THE
REQUIRED MINIMUM DISTRIBUTION FOR THE YEAR IN WHICH THE FUNDS ARE
PAID TO PRUDENTIAL:
I understand it is my responsibility to remove the minimum
distribution from the purchase payment prior to sending money to
Prudential with this application. Unless we are notified
otherwise, Prudential will assume that the owner is satisfied with
the required minimum distributions from other IRA funds.
By signing this form, the trustee(s)/officer(s) hereby represents
that the trustee(s)/officer(s) possess(es) the authority, on
behalf of the non-natural person, to purchase the annuity contract
and to exercise all rights of ownership and control over the
contract, including the right to make purchase payments to the
contract.
I understand that any amount of purchase payments allocated to the
MVA option may increase or decrease due to such adjustment prior
to the maturity of the interest cell.
OWNER'S TAX CERTIFICATION
------------------------------------------------------------------
Under penalty of perjury, I certify that the taxpayer
identification number (TIN) I have listed on this form is my
correct taxpayer identification number. I HAVE/HAVE NOT (circle
one) been notified by the Internal Revenue Service that I am
subject to backup withholding due to underreporting of interest or
dividends.
------------------------------------------------------------------
THE INTERNAL REVENUE SERVICE DOES NOT REQUIRE YOUR
CONSENT TO ANY PROVISION OF THIS DOCUMENT
OTHER THAN THE CERTIFICATIONS REQUIRED
TO AVOID BACKUP WITHHOLDING.
------------------------------------------------------------------
We must have both the owner's and annuitant's signatures even if
this contract is owned by a trust, corporation, or other entity.
If the annuitant is a minor, please provide the signature of a
legal guardian or custodian.
I hereby certify that all the information contained in this
application is complete and true to the best of my knowledge.
X /s/ John Doe 05 04 2001
--------------------------------------- -- -- ----
Contract owner's signature and date month day year
X /s/ Mary Doe 05 04 2001
--------------------------------------- -- -- ----
Joint owner's signature (if applicable) month day year
and date
X /s/ John Doe 05 04 2001
--------------------------------------- -- -- ----
Annuitant's signature (if applicable) month day year
and date
X
--------------------------------------- -- -- ----
Co-annuitant's signature (if applicable) month day year
and date
/s/ Anytown, N.Y.
---------------------------------------
Signed at (city, state)
- --------------------------------------------------------------------------------
ORD 99669 New York -- Third Party Ed. 5/2001 Third Party
Page 5 of 6
14 FINANCIAL Commission Option (Choose only one.):
PROFESSIONAL'S 1. [ ]No Trail 2. [ ]Mid Trail
SIGNATURE(S) 3. [ ]High Trail 4. [ ]Levelized
Note: If an option is not selected, the default option will
be Option 3.
This application is submitted in the belief that the
purchase of this contract is appropriate for the applicant
based on the information provided and as reviewed with the
applicant. Reasonable inquiry has been made of the owner
concerning the owner's overall financial situation, needs,
and investment objectives.
The financial professional hereby certifies that all
information contained in this application is true to the
best of his or her knowledge.
RICHARD ROE 1 2 3 4 5 6 7 8 9
----------------------------------- - - - - - - - - -
Financial professional's name Firm FA contract number
(Please print)
9 8 7 6 5 4 3 2 1
- - - - - - - - -
Prudential contract
number
X /s/ Richard Roe 05 04 2001
----------------------------------- -- -- ----
Financial professional's month day year
signature and date
----------------------------------- - - - - - - - - -
Second financial professional's Firm FA contract number
name(Please print)
- - - - - - - - -
Prudential contract
number
X
----------------------------------- -- -- ----
Second financial professional's month day year
signature and date
Sunnytown - SNTN 8 8 8 5 5 5 - 5 5 5 5
---------------------------------- - - - - - - - - - -
Branch name and code Financial professional's
telephone number
- --------------------------------------------------------------------------------
15 ADDITIONAL
REMARKS
-----------------------------------------------------------
-----------------------------------------------------------
-----------------------------------------------------------
-----------------------------------------------------------
-----------------------------------------------------------
-----------------------------------------------------------
- --------------------------------------------------------------------------------
STANDARD PRUDENTIAL ANNUITY SERVICE CENTER
MAIL TO: THIRD PARTY
PO BOX 8210
PHILADELPHIA, PA 19101
OVERNIGHT PRUDENTIAL ANNUITY SERVICE CENTER
MAIL TO: THIRD PARTY
2101 WELSH ROAD
DRESHER, PA 19025
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ORD 99669 NEW YORK - THIRD PARTY Ed. 5/2001 THIRD PARTY
Page 6 of 6
NY
MEMORANDUM DESCRIBING THE VARIABLE MATERIAL
CONTAINED IN APPLICATION FORM ORD 99669-NEW YORK
AND ORD 99669-NEW YORK-THIRD PARTY
SECTION 7. PURCHASE PAYMENT ALLOCATION
The allocation options have been bracketed to indicate that they are
illustrative, i.e., we may rename, add to, delete from, or substitute other
allocation options for those shown in the application.