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PGIM - Name - Change - Form

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109 views3 pages

PGIM - Name - Change - Form

Uploaded by

kritikafinancialservices1
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Prudential Mutual Fund Services LLC

For assistance:
Clients: (800) 225-1852
Financial Professionals: (888) 778-5471
Name Change Form
What to do to submit your name change request:
1. Decide
You can use this form to request a change to your name on your mutual fund account due to marriage, divorce, court order,
or other reason.
Do not use this form to transfer ownership to another individual. Use the Registration Change Form (MF 1002) to
transfer ownership.

2. Complete
Follow the instructions in each section and complete all applicable sections. Depending on the reason for your name
change, you will need to provide a copy of one of the following documents:
• A certified court document authorizing the name change
• Marriage Certificate
• Divorce Decree
• Birth Certificate to show the minor’s date of birth. If the minor is under age 14, the custodian/legal guardian must
sign the form. If the minor is over age 14, he/she must sign with their former name and new name.

Note: You must have your signature notarized in section 4 if the value of any fund in the account is over $25,000.

3. Return
Send us your completed form. Also, include any of the above documentation that is required to complete your request.

Return form to:

Standard Mail to Overnight mail to


Prudential Mutual Fund Services LLC Prudential Mutual Fund Services LLC
P.O. Box 534432 Attention 534432
Pittsburgh, PA 15253-4432 500 Ross Street, 154-0520
Pittsburgh, PA 15262
Prudential Mutual Fund Services LLC

For assistance:
Clients: (800) 225-1852
Financial Professionals: (888) 778-5471
Name Change Form

1. Account Information
Print account information exactly as it appears on your account statement

Account number Social Security number

First name Middle initial Last name

Street Address Apt/Suite

City State ZIP Code

Home phone Cell phone Email address

2. Certification and Reason for Name Change

I hereby certify that


Print former name

was changed to and is one and the same person.


Print new name

Reason for Name Change: Marriage Divorce Court Order

Other

MF1003 Ed. 11/2024 page 1 of 2


3. Authorization and Tax Certification
Please review modify any applicable portions below

Under penalties of perjury, I certify that


(1) The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be
issued to me); and

(2) I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been
notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report
all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and

(3) I am a U.S. citizen or other U.S. person (defined below); and

(4) The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.

If you crossed out item 3 above, please indicate country of citizenship and attach applicable Internal Revenue Service
Form W-8(BEN, BEN-E,EXP, ECI, IMY).

Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently
subject to backup withholding because you have failed to report all interest and dividends on your tax return. For
real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured
property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments
other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN.

A notarized signature is required if the dollar value of any fund in the account is over $25,000.

For the purpose of processing a request in an efficient and prompt manner, I authorize Prudential to consolidate and
disclose completed forms and documents to appropriate associates for each and every one of Prudential Financial, Inc.’s
affiliates or business units to which a request is presented.
A notary public may be obtained in some banks and other financial institutions, as well as legal offices and government
agency offices. In some areas, there may be a privately owned notary office.

By signing below, I certify and acknowledge that the information provided on this form is correct.
The IRS does not require your consent to any provision of this document other than certification required to avoid backup
withholding.

X X
Signature of former name Signature of new name

Date

Place notary seal and signature here.

MF1003 Ed. 11/2024 page 2 of 2

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