Application




	Prudential Defined Income Variable Annuity Application Annuities are issued by Pruco Life Insurance Company of New Jersey	Annuities Service Center Financial Professionals: 1-800-513-0805 Fax 1-800-576-1217 www.prudentialannuities.com Regular Mail Delivery Annuities Service Center P.O. Box 7960 Philadelphia, PA 19176 Overnight Service, Certified or Registered Mail Delivery Prudential Annuities Service Center 2101 Welsh Road Dresher, PA 19025

SECTION 1 n LIFETIME INCOME SELECTION (One must be chosen)


¨ Single Designated Life		¨ Spousal Designated Lives



SECTION 2 n OWNERSHIP INFORMATION

A. TYPE OF OWNERSHIP

Non Entity:

¨ Natural Person(s)

Entity:

¨ Custodian

¨ C Corporation*

¨ S Corporation*

¨ Trust*

*If the Owner is a Trust, Corporation or other entity you must complete and submit the Certificate of Entity form with this application.

B. OWNER

Name (First, Middle, Last, or Trust / Entity)

¨ Male

¨ Female

Birth Date (Mo - Day - Yr)

SSN / TIN

- -

Street Address

City

State

ZIP


		Telephone Number


		¨ U.S. Citizen		¨ Resident Alien/Citizen of:

¨ Non-Resident Alien/Citizen of:

(Submit IRS Form W-8 (BEN, ECI, EXP or IMY))

C. CO-OWNER - Not available for entity-owned Annuities or Qualified Annuities. If a Co-owner is elected,

then the Spousal Designated Lives option must be chosen above

Check here to designate the Co-Owners as each other’s Primary Beneficiary.

¨ Name (First, Middle, Last)

¨ Male

¨ Female

Birth Date (Mo - Day - Yr)

SSN / TIN

- -

Street Address

City

State

ZIP

Telephone Number

¨ U.S. Citizen

¨ Resident Alien/Citizen of:

¨ Non-Resident Alien/Citizen of:

(Submit IRS Form W-8 (BEN, ECI, EXP or IMY))

Relationship to Owner:

(Continued)


P-BBND-APP(2/13) NY				ORD 206386 NY		page 1 of 6

Indicate classifications of each Beneficiary Percentage. of benefit for all Primary Beneficiaries must total 100%. Percentage of benefit for all Contingent Beneficiaries must total 100%. If the Co-Owners have been chosen as each other’s Primary Beneficiary, then only Contingent Beneficiaries may be designated below.

*The following information is required if the contract being requested is an employer plan.

Make all checks payable to Pruco Life Insurance Company of New Jersey. Purchase Payment amounts may be restricted by Pruco Life Insurance Company of New jersey; please see your prospectus for details.

Your purchase payment(s) will be allocated 100% to the AST Long Duration Bond Portfolio.

By providing my e-mail address below, and my signature in Section 10 of this application, I consent to receive and accept documents electronically during the duration of my variable annuity contract. These documents include, but are not limited to: account statements, confirmations, privacy notices, tax documents, prospectuses and prospectus supplements, annual and semi-annual reports, proxy statements, and correspondence. This consent will continue unless and until I revoke my consent by notifying Prudential at which time I will begin receiving paper documents by mail. I understand that e-mail notifications will be sent to me, indicating that documents are available, and will include instructions on how to quickly and easily access the documents by going to Prudential’s website.

Certain types of correspondence may still be delivered to you by paper mail. Registration on Prudential’s website is required for electronic delivery. There are no fees charged by Prudential for the e-Documents service or for paper documents. You must have a computer with Internet access, an active e-mail account, and Adobe Acrobat Reader to view your documents electronically. You can download Adobe Acrobat at no charge. See your Internet Service Provider for any other access fees that may apply.

Pursuant to Section 3 of the federal Defense of Marriage Act (“DOMA”), same-sex marriages currently are not recognized for purposes of federal law. Therefore, the favorable income-deferral options afforded by federal tax law to an opposite-sex spouse under Internal Revenue Code sections 72(s) and 401(a)(9) are currently NOT available to a same-sex spouse. Same-sex spouses who own or are considering the purchase of annuity products that provide benefits based upon status as a spouse should consult a tax advisor. To the extent that an annuity contract or certificate accords to spouses other rights or benefits that are not affected by DOMA, same-sex spouses remain entitled to such rights or benefits to the same extent as any annuity holder’s spouse.


SECTION 9 n OWNER & FINANCIAL PROFESSION – REPLACEMENT INFORMATION


Replacement Questions	Owner Response	Financial Professional Response
Does the Owner have any existing individual life insurance policies or annuity contracts?	¨ YES ¨ NO	¨ YES ¨ NO
Will this annuity replace or change any existing individual life insurance policies or annuity contracts? (If yes, complete the following and submit the required Regulation 60 paperwork.) If yes - Company: \| \| Policy #: \| \| Year Issued:\| \|	¨ YES ¨ NO	¨ YES ¨ NO


SECTION 10 n OWNER SIGNATURE(S)

By signing below and having entered an e-mail address in Section 5, E-Documents, I am providing my informed consent to receive standard regulatory documents and other documents listed in Section 5 by electronic delivery.


		(If contract is issued in a State other than the Owner’s State
REQUIRED	State where signed	of Residence , a Contract Situs Form may be required.)

OWNER’S TAX CERTIFICATION (SUBSTITUE W-9)

Under penalty of perjury, I certify that the taxpayer identification number (TIN) I have listed on this form is my correct TIN.

I further certify that the citizenship/residency status I have listed on this form is my correct citizenship/residency status.

¨ I have 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.


SIGN HERE		- -
	Owner Signature	Month Day Year


TITLE (if any)
	If signing on behalf of an entity, you must indicate your official title / position with the entity; if signing as a Trustee for a Trust, please provide the Trustee designation.


SIGN HERE		- -
	Co-Owner Signature	Month Day Year


SIGN HERE		- -
	Annuitant Signature (if different from Owner)	Month Day Year


P-BBND-APP(2/13) NY		ORD 206386 NY \| page 5 of 6

I am authorized and/or appointed to sell this variable annuity. I have fully discussed and explained the variable annuity features and charges including restrictions to the Owner. I believe this variable annuity is suitable given the Owner’s investment time horizon, goals and objectives, and financial situation and needs. I represent that: (a) I have delivered current applicable prospectuses and any supplements for the variable annuity (which includes summary descriptions of the underlying investment options); and (b) have used only current Pruco Life Insurance Company of New Jersey approved sales material.

I certify that I have truly and accurately recorded on this application the information provided by the applicant. I acknowledge that Pruco Life Insurance Company of New Jersey will rely on this statement.


Employer Plan No. (if available)				Employer Plan Phone No.

Employer Plan Name				Employer Plan Contact Name


If needed for:	• Special Instructions	• Beneficiaries	• Contingent Annuitant (for custodial business only)
	• Annuity Replacement	• Entity Authorized Individuals


¨ Non-Resident Alien/Citizen of:				(Submit IRS Form W-8 (BEN, ECI, EXP or IMY))


SECTION 3 n BENEFICIARY INFORMATION - NOTE: IF MORE THAN 4 BENEFICIARIES SEE SECTION 7


¨ Non-Qualified ¨ SEP-IRA*				¨ Roth 401(k)*(Plan Year)				¨ 457(b)*(gov’t. entity)


¨ 401*(Plan Year)						¨ IRA ¨ Roth IRA ¨ 403(b)*				¨ 457(b)*(501(c) tax-exempt)


SECTION 11 n FINANCIAL PROFESSIONAL ACKNOWLEDGEMENTS AND SIGNATURE(S)


For Broker/Dealer Use Only
	Networking No.	Annuity No. (If established)