Prudential Enrollment Form – Fill Out and Use This PDF

Social Security number

Daytime telephone number

First name

MI Last name

Address

City

State

ZIP code

month

day

year

month

day

year

Date of rehire (if applicable)

Marital status

Married

Single, widowed or legally divorced

month

day

year

Amount to

Before-Tax Contribution Election. I wish to contribute

% (1% to 100% in whole percentages) of

be Deferred

my salary per pay period.

Investment

Fill out Option I, Option II or Option III. Please complete only one.

Allocation

By completion of Option I or Option II you enroll in GoalMaker, Prudential’s asset allocation program, and you direct

(Pleasefill

Prudential to invest your contribution(s) according to a GoalMaker model portfolio that is based on your risk tolerance

and time horizon. You can also direct Prudential to automatically rebalance your account quarterly according to the

outOption

model portfolio chosen. Enrollment in GoalMaker can be canceled at anytime.

I,OptionII,

Please refer to the Retirement Planning Guide for more information on rebalancing and age adjustment.

orOption

III.Donot

Option I or Option II must be completed accurately, otherwise your investment allocation will be placed in GoalMaker

filloutmore

with age adjustment.

thanone

Option III must be completed accurately and received by Prudential before assets are accepted; otherwise,

section.)

contributions will be placed in the default investment option selected by your plan. Upon receipt of your completed

enrollment form, all future contributions will be allocated according to your investment selection. You must contact

Prudential to transfer any existing funds from the default option.

Ed. 07/2010

Important information and signature required on the following page(s)

%

23

T. Rowe Price Retirement Income

%

4Q

Invesco Van Kampen Growth and Income Fund Y

%

57

Legg Mason ClearBridge Appreciation Fund Class I

%

W1

SA/T. Rowe Price Growth Stock Strategy

%

KU

Vanguard Institutional Index Fund

%

58

Morgan Stanley Inst Mid Cap Growth I

%

1W

Perkins Mid Cap Value Fund Class A

%

KT

Pioneer Mid Cap Value Fund (Class A Shares)

%

RP

Vanguard Mid Cap Index Instl

%

MQ

Allianz NFJ Small Cap Value Instl

%

M4

Legg Mason ClearBridge Small Cap Growth Fund Class I

%

VQ

Pennsylvania Mutual Inv

%

RO

Vanguard Small Cap Index Insl

%

P5

American Funds EuroPacific Growth Fund R4

%

JL

Oppenheimer Developing Markets Y

%

43

Vanguard REIT Index Fund

1

0

0

%

Total

Your

I authorize my employer to reduce my compensation as directed in compliance with the terms of the plan.

Authorization

I choose not to participate in my employer-sponsored retirement plan.

Signature

X

Date