Custodian/Guardian for a minor Beneficiary (required, cannot be same as Investor or Co-Investor):
D. ERISA Plan Asset Regulations
All investors are required to complete Appendix B attached hereto.
4. Contact Information (If different than provided in Section 3A)
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Mailing Address | | City | | State | | Zip Code |
5. Select How You Want to Receive Your Distributions (Please Read Entire Section and Select Only One)
You are automatically enrolled in our Distribution Reinvestment Plan, unless you are a resident of ALABAMA, ARKANSAS, IDAHO, KANSAS, KENTUCKY, MAINE, MARYLAND, MASSACHUSETTS, NEBRASKA, NEW JERSEY, NORTH CAROLINA, OHIO, OKLAHOMA, OREGON, TEXAS, VERMONT OR WASHINGTON.
☐ | If you are not a resident of the states listed above, you are automatically enrolled in the Distribution Reinvestment Plan; please check here if you DO NOT wish to be enrolled in the Distribution Reinvestment Plan and complete the Cash Distribution Information section below. |
ONLY complete the following information if you do not wish to enroll in the Distribution Reinvestment Plan. For custodial held accounts, if you elect cash distributions the funds must be sent to the custodian.
A. | ¨ | Check mailed to street address in 3A (only available for non-custodial investors). |
B. | ¨ | Check mailed to secondary address in 3B (only available for non-custodial investors). |
C. | ¨ | Direct Deposit by ACH (only available for non-custodial investors). PLEASE ATTACH A PRE-VOIDED CHECK |
D. | ¨ | Check mailed to Third party Financial Institution (complete section below). |
¨ If you ARE a resident of Alabama, Arkansas, Idaho, Kansas, Kentucky, Maine, Maryland, Massachusetts, Nebraska, New Jersey, North Carolina, Ohio, Oklahoma, Oregon, Texas, Vermont or Washington, you are not automatically enrolled in the Distribution Reinvestment Plan. Please check here if you wish to enroll in the Distribution Reinvestment Plan. You will automatically receive cash distributions unless you elect to enroll in the Distribution Reinvestment Plan.
I authorize PGIM Private Credit Fund or its agent to deposit my distribution into my checking or savings account. This authority will remain in force until I notify PGIM Private Credit Fund in writing to cancel it. In the event that PGIM Private Credit Fund deposits funds erroneously into my account, they are authorized to debit my account for an amount not to exceed the amount of the erroneous deposit.
Bank Name | | Bank Account Number | | Bank Routing Number |
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Name of Depositor (first, middle initial, last name) | | | | Name of Joint Depositor (first, middle initial, last name) |
6. Designated Representative or Trusted Contact
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First Name | | MI | | Last Name | | | | |
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Social Security Number / Tax ID | | | | Daytime Phone Number | | | | |
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Residential Street Address* | | | | City | | State | | | Zip Code | |
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Email Address | | | | | | | | |
*Legal address cannot be a P.O. Box