Fill - 21575 21575 (New York Life)

21575 (5/2020) Page 1 of 10

NYLIAC Single Premium Variable Universal Life,

NYLIAC Variable Universal Life 2000,

NYLIAC Variable Universal Life,

NYLIAC Survivorship Variable Universal Life,

NYLIAC Variable Universal Life Provider,

New York Life Survivorship Variable Universal Life Accumulator,

New York Life Variable Universal life Accumulator,

New York Life Legacy Creator Single Premium Variable Universal Life,

New York Life Variable Universal Life Accumulator Plus

New York Life Variable Universal Life Accumulator II

Date: _____________________________________________________________

Policy Number: _____________________________ Policyowner(s): ________________________________________________________________

Insured(s): ___________________________________________________________________________________________________________

Instructions:

1. If you wish to request a one-time Partial Withdrawal, complete Sections A and C through E.

2. If you wish to set up or modify an automated Periodic Partial Withdrawal Arrangement, complete Sections B through E.

3. Read the Important Income Tax Information on page 10.

4. Date and sign page 8, Section F of this form and secure all other required signatures. If the policy is jointly owned and has another

designee(s) who are authorized to request transactions on the policy, the signatures of all joint owners and designees are required. All

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Guarantee of the policyowner(s) signature.

6. If you have any questions, please contact one of our Customer Service Representatives toll-free at 1-800-CALL-NYL. For online policy

information and service, please visit us at newyorklife.com.

7. If you are using the funds from this policy to purchase/fund another policy, please consider all aspects of the transaction before making a

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including the face amount and surrender value of the policy from which the funds are being released.

Please read the product prospectus for further details regarding Partial Withdrawals and Periodic Partial Withdrawals.

Please Note: If NYLIAC receives this request and any required information is incomplete, this request will not be processed. We will notify you if

your request is incomplete. If you resubmit the request, the transaction(s) will then be effective as of the date on which we receive this completed

resubmission.

NEW YORK LIFE INSURANCE AND ANNUITY CORPORATION (NYLIAC)

(A Delaware Corporation)

3$57,$/:,7+'5$:$/3(5,2',&3$57,$/:,7+'5$:$/5(48(67)250

For Variable Universal Life policies: New York Life, Variable Products Service Center

Madison Square Station, PO Box 922, New York, NY 10159

RETURN FORM TO:

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21575 (5/2020) Page 2 of 10

SECTION A PARTIAL WITHDRAWAL

3/($6(,1',&$7(7+($02817<28:,6+72:,7+'5$:$1'&203/(7(7+(6(&7,216&(2)7+,6)250

For SPVUL, VUL 2000, VUL, and SVUL, we impose a fee, not to exceed the lesser of $25 or 2% of the amount withdrawn, for each withdrawal. The

minimum amount that may be withdrawn is $500. For VUL 2000, VUL, and SVUL, we will not allow a partial withdrawal if it would reduce the face

amount of your policy (not including riders) below the minimum face amount ($50,000 for VUL 2000 and VUL; and $100,000 for SVUL). For SPVUL,

we will not allow a partial withdrawal if it would reduce the Cash Surrender Value below the minimum initial single premium required by issue age

($5,000 for issue ages 17 and below; $100,000 for issue ages 18 and above).

For VUL Provider, Legacy Creator SPVUL, VUL Accumulator, VUL Accumulator II, VUL Accumulator Plus, and SVUL Accumulator, we may impose a

fee that will not exceed $25 for each withdrawal. The minimum amount that may be withdrawn is $100 for VUL Provider, VUL Accumulator and VUL

Accumulator Plus; and $500.00 for Legacy Creator SPVUL and SVUL Accumulator. For VUL Accumulator, VUL Accumulator II, SVUL Accumulator,

and VUL Accumulator Plus, we will not allow a partial withdrawal if it would reduce the face amount of your policy (not including riders) below the

minimum face amount ($50,000 for VUL 2000, VUL Accumulator, VUL Accumulator II, and VUL Accumulator Plus; and $100,000 for VUL Provider and

SVUL Accumulator). For Legacy Creator SPVUL, we will not allow a partial withdrawal if it would cause the policy’s Cash Surrender Value to fall below

$10,000.

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0HGDOOLRQ6LJQDWXUH*XDUDQWHHRIWKHSROLF\KROGHUVVVLJQDWXUH

,5(48(67$:,7+'5$:$/$028172)BBBBBBBBBBBBBBBBBBBBBBBBBBBB

,I\RXUDGGUHVVRUEDQNDFFRXQWLQIRUPDWLRQKDVEHHQRQÀOHZLWKXVIRUOHVVWKDQGD\VZHPD\UHTXLUHDGGLWLRQDOYHULÀFDWLRQRI\RXU

identity, in a form acceptable to us, before we will process a request to send surrender proceeds electronically to that bank account or

through the mail to that address.

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

1. (Gross) I understand that I may receive less than

this amount if I elect to have taxes withheld and/or a

surrender charge applies.



2.1HW,ZLVKWRUHFHLYHWKHIXOODPRXQWVSHFL¿HGDERYH,

understand that the amount deducted from my policy may be

greater if I elect to have taxes withheld and/or a surrender

charge applies.

If this partial withdrawal includes monies to be withdrawn for the purposes of paying a premium for another NYLIAC, New York Life, or a Long Term

Care product, please indicate the policy number and payment type.

Please Note: Loan Repayments are not eligible for Long Term Care products.

The partial withdrawal will be used to pay the premiums on the following policy number:

________________________________________________________

Premium Payment Type:



Scheduled Premium Payment



Additional Premium Payment



Loan Repayment

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21575 (5/2020) Page 3 of 10

SECTION B 3(5,2',&3$57,$/:,7+'5$:$/33:$55$1*(0(17

For VUL, VUL 2000, VUL Provider, VUL Accumulator, VUL Accumulator Plus Policies and Accumulator II Policies Only

Please complete this section if you wish to receive Periodic Partial Withdrawals (PPW) on a regular schedule. Only one PPW

arrangement may exist for each policy. If a new election form is received it will cancel any previous election form. You may not elect to

receive Periodic Partial Withdrawals if you are currently making scheduled deposits to your policy via automatic deposits from your

EDQN([FHSWDVSURYLGHGEHORZ3HULRGLF3DUWLDO:LWKGUDZDOVZLOOFRQWLQXHXQWLOQRWLÀFDWLRQWRWHUPLQDWHWKHPLVUHFHLYHGE\1</,$&

33:DUUDQJHPHQWVFDQQRWEHHOHFWHGZKLOHWKH1R/DSVH*XDUDQWHHSURYLVLRQLVLQHIIHFWLI\RXKDYHD*XDUDQWHHG0LQLPXP

'HDWK%HQHÀW5LGHUDQ,QWHUPHGLDWH1R/DSVH*XDUDQWHH5LGHU\RXUSROLF\LVD0(&RULI\RXUSROLF\LVEHORZLWVPLQLPXPIDFH

amount. If a PPW would cause the policy’s Face Amount to be less than the required face amount ($100,000 for VUL Provider; and

$50,000 for VUL, VUL 2000, VUL Accumulator, VUL Accumulator II and VUL Accumulator Plus), we will not process the PPW and

the arrangement will be suspended. For the PPW arrangement to continue as scheduled, the Cash Surrender Value must be maintained

at a $2,000 minimum and PXVWEHVXI¿FLHQWWRFRYHUWKHSROLF\¶VPRQWKO\FKDUJHV,IWKH&DVK6XUUHQGHU9DOXHIDOOVEHORZWKLVPLQLPXPDQG

RULVLQVXI¿FLHQWWRFRYHUWKHPRQWKO\FKDUJHVWKLVRSWLRQZLOOEHVXVSHQGHGWe will notify you if this occurs. If the Cash Surrender Value

VXEVHTXHQWO\UHDFKHVWKHPLQLPXPDQGRUWKHPRQWKO\FKDUJHVKDYHEHHQVDWLV¿HGWKH33:DUUDQJHPHQWZLOODXWRPDWLFDOO\UHVWDUWRQ

the next scheduled date.

We will automatically terminate your PPW arrangement when total withdrawals taken (including PPWs) equal the total premiums paid

under the policy. (Due to this rule, your last PPW payment may be smaller than your requested PPW amount.) Otherwise, PPWs will

continue until NYLIAC receives your notice to terminate them.

7RSURFHVVD33:DUUDQJHPHQW1</,$&PXVWUHFHLYHWKLVIRUPDWOHDVW¿YHEXVLQHVVGD\VEHIRUHWKHGDWHWKH33:VDUHWREHJLQ7KH33:V

will be effective on the day of the month you specify (except for the 29

, 30

or 31

of a month). If your request for this option is received less than

¿YHEXVLQHVVGD\VSULRUWRWKHGDWH\RXUHTXHVWHGLWWREHJLQWKH33:VZLOOEHJLQRQHPRQWKDIWHUWKHGDWH\RXUHTXHVWHGLWWREHJLQ7KH

PPW arrangement cannot be set up more than three months in advance of the start date.

21575 0520 03

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21575 (5/2020) Page 4 of 10

SECTION B 3(5,2',&3$57,$/:,7+'5$:$/33:$55$1*(0(17&RQWLQXHG

I ELECT TO RECEIVE SCHEDULED PAYMENTS OF:



$6SHFLÀHG$PRXQW0LQLPXPBBBBBBBBBBBBBBBBBBB

7KHVSHFL¿HGDPRXQWZLOOEHZLWKGUDZQIRUHDFKSD\PHQW$VXUUHQGHUFKDUJHPD\DSSO\

)RU98/DQG98/ZHPD\LPSRVHDIHHQRWWRH[FHHGWKHOHVVHURIRURIWKHDPRXQWZLWKGUDZQRQWKHÀUVW

withdrawal. For VUL Provider, VUL Accumulator, VUL Accumulator Plus, and Accumulator II, we may impose a fee not to exceed

RQWKHÀUVWZLWKGUDZDO

&KRRVHRQHRSWLRQ



1. (Gross) I understand that I may receive less than this amount if I elect to have taxes withheld and/or a surrender charge applies.



2. 1HW,ZLVKWRUHFHLYHWKHIXOODPRXQWVSHFL¿HGDERYH,XQGHUVWDQGWKDWWKHDPRXQWGHGXFWHGIURPP\SROLF\PD\EHJUHDWHULI,HOHFW

to have taxes withheld and/or a surrender charge applies.

If any of these PPW options includes monies to be withdrawn for the purposes of paying a premium for another NYLIAC, New York Life Insurance

Company, or a Long Term Care product, please indicate the policy number:

The PPW will be used to pay the premiums on the following policy number:

____________________________________________________

INDICATE FREQUENCY OF PARTIAL WITHDRAWALS:



Monthly



Quarterly



Semi-Annually



Annually

PLEASE INDICATE THE DATE FOR THE FIRST PAYMENT TO BE WITHDRAWN FROM YOUR POLICY:

Payment dates may not be the 29

, 30

, or 31

of a month:____________________________________________________

Month Day Year

SECTION C ELECTRONIC FUNDS TRANSFER (EFT)

To have your Partial Withdrawal/ Periodic Partial Withdrawal payment(s) sent directly to your bank account, via Electronic Funds Transfer

()7SOHDVHSURYLGHWKHIROORZLQJLQIRUPDWLRQ,IZHDUHXQDEOHWRVHQG\RXUSD\PHQWVYLD()7WRWKHEDQNDFFRXQWSURYLGHGZHZLOO

VHQGDFKHFNWRWKHDGGUHVVRIUHFRUGRUWKHFXUUHQWDGGUHVVSURYLGHGRQSDJH

Name of Financial Institution and Branch Name (if any) ___________________________________________________________________

Address of Financial Institution ___________________________________________________________________

___________________________________________________________________

Routing Number of Financial Institution ___________________________________________________________________

Account Number for Deposit of Payments ___________________________________________________________________

Accountholder’s Name ___________________________________________________________________

Please Check One:



Checking Account



Saving Account

If the payment(s) are to be deposited into a Checking Account, please attach a voided check. If the payment(s) are to be deposited into a Savings

Account, please provide a deposit slipWKDWFRQ¿UPVWKHDFFRXQWDQGURXWLQJQXPEHUV

If the day you have chosen for your Periodic Partial Withdrawal payments falls on any day which is not a business day (e.g., a weekend or holiday)

your payment shall be made on the following business day. The unit value for each payment will be equal to the unit value for the respective

Allocation Alternative on the day the payment is made.

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21575 0520 04

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21575 (5/2020) Page 5 of 10

SECTION D ALLOCATION ALTERNATIVES

3/($6(,1',&$7(7+($0281772%(:,7+'5$:1)5207+()2//2:,1*,19(670(17',9,6,216$1'25),;('$&&2817

If no indication is given, payment(s) will be taken on a proportional basis, based on the allocation of the cash value in the Allocation Alternatives

at the time of the withdrawal.

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Morningstar Category assigned to the Investment Divisions by Morningstar Analytics as of December 31, 2019. Morningstar, Inc. is a widely-

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assets.

FOR VARIABLE UNIVERSAL LIFE PROVIDER PERIODIC PARTIAL WITHDRAWALS ONLY: Your Periodic Partial Withdrawal arrangement

ZLOOEHVXVSHQGHGLIWKHUHLVLQVXI¿FLHQWFDVKYDOXHLQDQ\RIWKHLQYHVWPHQWGLYLVLRQV\RXKDYHVHOHFWHG,IWKHFDVKYDOXHLQWKHLQYHVWPHQW

division(s) then reaches the minimum required, the Periodic Partial Withdrawal will automatically restart on the next scheduled date. Y

ou may

change your allocation alternatives for your Periodic Partial Withdrawal at any time.

1$0( 180%(5 1$0( 180%(5

Fixed Account 101 $

MainStay VP MacKay High Yield Corporate

Bond – Initial Class (Moderate) 110 $

Dollar Cost Averaging Plus/Extra Account

(1)

MainStay VP MacKay International Equity –

Initial Class (High) 109 $

MainStay VP Balanced – Initial Class

(Moderate) 145 $

MainStay VP MacKay Mid Cap Core – Initial

Class (High) 136 $

MainStay VP Bond – Initial Class (Moderate) 107 $

MainStay VP MacKay S&P 500 Index – Initial

Class (High) 105 $

MainStay VP CBRE Global Infrastructure –

Initial Class (Highest)

(2)(7)

176 $

MainStay VP MacKay Small Cap Core – Initial

Class (High) 180 $

MainStay VP Conservative Allocation – Initial

Class (Moderate) 148 $

MainStay VP MacKay Unconstrained Bond –

Initial Class (Moderate) 156 $

MainStay VP Emerging Markets Equity – Initial

Class (Highest)

(4)

163 $

MainStay VP Mellon Natural Resources –

Initial Class (Highest) 158 $

MainStay VP Epoch U.S. Equity Yield –

Initial Class (High) 121 $

MainStay VP Moderate Allocation – Initial

Class (Moderate) 149 $

MainStay VP Fidelity Institutional AM

Utilities – Initial Class (+LJK) 160 $

MainStay VP Moderate Growth Allocation –

Initial Class (High) 150 $

MainStay VP Floating Rate – Initial Class

(Moderate) 144 $

MainStay VP PIMCO Real Return – Initial

Class (Moderate) 162 $

MainStay VP Growth Allocation – Initial

Class (High) 151 $

MainStay VP Small Cap Growth – Initial Class

(High)

(9)

164 $

MainStay VP Income Builder – Initial Class

(Moderate) 106 $

MainStay VP T. Rowe Price Equity Income –

Initial Class (High)

(4)

161 $

MainStay VP Indexed Bond – Initial Class

(Moderate)

(2)

186 $

MainStay VP U.S. Government Money

Market – Initial Class (Low) 102 $

MainStay VP IQ Hedge Multi-Strategy – Initial

Class (Moderate)

(3)

192 $

MainStay VP Winslow Large Cap Growth -

Initial Class (High)

(8)

122 $

MainStay VP Janus Henderson Balanced –

Initial Class (Moderate) 159 $

AB VPS Small/Mid Cap Value

Portfolio – Class A (High) 152 $

MainStay VP MacKay Common Stock –

Initial Class (High) 108 $

American Funds IS Asset Allocation Fund –

Class 2 (Moderate)

(2)

191 $

MainStay VP MacKay Convertible – Initial

Class (Moderate) 119 $

American Funds IS Blue Chip Income and

Growth Fund – Class 2 (High)

(2)

188 $

MainStay VP MacKay Government – Initial

Class (Moderate) 103 $

American Funds IS Global Small Capitalization

Fund – Class 2 (High)

(2)

174 $

MainStay VP MacKay Growth – Initial Class

(High)

(4)

104 $

American Funds IS Growth Fund –

Class 2 (High)

(2)

187 $

Allocation Alternative Listing Continues on the Next Page

21575 0520 05

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21575 (5/2020) Page 6 of 10

1$0( 180%(5 1$0( 180%(5

American Funds IS New World Fund

–

Class 2 (Highest) 172 $

Invesco V.I. American Value Fund –

Series I (High) 316 $

BlackRock

Global Allocation V.I. Fund –

Class I (Moderate) 157 $

Invesco V.I. International Growth Fund –

Series l (High) 154 $

BlackRock

High Yield V.I. Fund – Class I

(Moderate) 173 $

Janus Henderson Enterprise Portfolio –

Institutional Shares (High)

(2)

206 $

BNY Mellon IP Technology Growth Portfolio –

Initial Shares (Highest)

(5)

138 $

Janus Henderson Global Research Portfolio –

Institutional Shares (High) 117 $

ClearBridge Variable Appreciation Portfolio –

Class I (High)

(2)

185 $

Legg Mason/QS Aggressive Model Portfolio –

Class I (High)

(2)(3)

231 $

Columbia Variable Portfolio – Commodity

Strategy Fund – Class 1 (High)

(2)

175 $

Legg Mason/QS Conservative Model Portfolio –

Class I (Moderate)

(2)(3)

227 $

Columbia Variable Portfolio – Emerging

Markets Bond Fund – Class 1 (Moderate)

(2)

177 $

Legg Mason/QS Moderately Aggressive Model

Portfolio – Class I (Moderate)

(2)(3)

230 $

Delaware VIP

Emerging Markets Series –

Standard Class (Highest) 322 $

Legg Mason/QS Moderately Conservative

Model Portfolio – Class I (Moderate)

(2)(3)

228 $

Delaware VIP

Small Cap Value Series –

Standard Class (High) 323 $

Legg Mason/QS Moderate Model Portfolio –

Class I (Moderate)

(2)(3)

229 $

DWS Alternative Asset Allocation VIP–

Class A (Moderate)

(2)

179 $

LVIP SSgA International Index Fund –

Standard Class (High)

(2)

195 $

DWS Small Cap Index VIP –

Class A (High)

(2)

310 $

LVIP SSgA Mid-Cap Index Fund – Standard

Class (High)

(2)

194 $

DWS Small Mid Cap Value VIP –

Class A (High) 153 $

MFS

International Intrinsic Value Portfolio –

Initial Class (High)

(6)

324 $

Fidelity

VIP Contrafund

– Initial

Class (High) 115 $

MFS

Investors Trust Series – Initial Class

(High) 125 $

Fidelity

VIP Emerging Markets Portfolio –

Initial Class (Highest)

(2)

190 $

MFS

Mid Cap Value Portfolio – Initial Class

(High)

(2)(3)

225 $

Fidelity

VIP Equity-Income

Portfolio –

Initial Class (Moderate) 113 $

MFS

New Discovery Series – Initial Class

(High) 216 $

Fidelity

VIP Freedom 2020 Portfolio – Initial

Class (Moderate) 339 $

MFS

Research Series – Initial Class

(High) 126 $

Fidelity

VIP Freedom 2030 Portfolio – Initial

Class (Moderate) 340 $

Morgan Stanley VIF U.S. Real Estate

Portfolio – Class I (High) 212 $

Fidelity

VIP Freedom 2040 Portfolio – Initial

Class (Moderate) 341 $

Neuberger Berman AMT Mid Cap Growth –

Class I (High) 207 $

Fidelity

VIP Growth Opportunities Portfolio –

Initial Class (Moderate) 342 $

PIMCO VIT Income Portfolio – Institutional

Class (Moderate)

(2)(3)

226 $

Fidelity

VIP Health Care Portfolio – Initial

Class (High)

(2)

199 $

PIMCO VIT International Bond Portfolio

(U.S. Dollar-Hedged) – Institutional Class

(Moderate) 171 $

Fidelity

VIP Mid Cap Portfolio – Initial

Class (High) 202 $

PIMCO VIT Low Duration Portfolio – Institutional

Class (Low)

(2)

178 $

Invesco Oppenheimer V.I. Main Street Small

Cap Fund

– Series I Shares (High)

(2)(3)

223 $

PIMCO VIT Total Return Portfolio – Institutional

Class (Moderate) 344 $

TOTAL $

(1) DCA Plus only applies to VUL 2000, VUL Provider, VUL Accumulator, VUL Accumulator II, VUL Accumulator Plus, SVUL Accumulator and Survivorship VUL. For VUL

2000, VUL Provider, VUL Accumulator and SVUL Accumulator, the DCA Plus fund number is 302; for VUL Provider (with Alternative Cash Surrender Value), the DCA Plus

fund number is 303; for Survivorship VUL, the DCA Plus fund number is 304. For Legacy Creator SPVUL, the DCA Extra fund number is 305.

(2) These funds are not available on NYLIAC Single Premium Variable Universal Life and New York Life Legacy Creator Single Premium Variable Universal Life products.

(3) These funds are not available on NYLIAC Survivorship Variable Universal Life or NYLIAC Variable Universal Life Provider products.

(4) Premiums or transfers will not be accepted into this Investment Division on or after 11/13/2017 if you did not have Cash Value in this Investment Division prior to

11/13/2017. If you remove all of your Cash Value from this Investment Division on or after 11/13/2017, you will not be allowed to reinvest in this Investment Division.

(5) Formerly known as Dreyfus IP Technology Growth Portfolio – Initial Shares. Effective 6/3/2019.

(6) Formerly known as MFS

International Value Portfolio – Initial Class. Effective 6/1/2019.

(7) Formerly known as MainStay VP Cushing Renaissance Advantage Fund – Initial Class. Effective 3/2/2020.

(8) Formerly known as MainStay VP Large Cap Growth – Initial Class. Effective 5/1/2020.

(9) Formerly known as MainStay VP Eagle Small Cap Growth – Initial Class. Effective 5/1/2020.

21575 0520 06

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21575 (5/2020) Page 7 of 10

SECTION E ,1&20(7$;:,7++2/',1*(/(&7,21

A partial withdrawal may result in a taxable gain reportable to the IRS on IRS Form 1099R. In addition, a 10% penalty tax may be imposed if you

PDNHDZLWKGUDZDOIURP\RXUOLIHLQVXUDQFHSROLF\WKDWLVDPRGL¿HGHQGRZPHQWFRQWUDFWDQG\RXDUHQRWGLVDEOHGRU\RXUHFHLYH\RXUGLVWULEXWLRQV

before you are age 59½. The withdrawals you receive are subject to federal income tax withholding unless you elect not to have federal income tax

withheld from the withdrawal. Please read the Important Tax Information before you select a withholding election.

You should consider very carefully which box you check. You should consult with your personal tax advisor, plan administrator, State

LQFRPHWD[DXWKRULW\RU\RXUORFDO,56RIÀFHLI\RXKDYHDQ\TXHVWLRQVDERXWLQFRPHWD[ZLWKKROGLQJ,56SXEOLFDWLRQ7D[:LWKKROGLQJ

and Estimated Tax) and IRS form W-9 may also be helpful.

3OHDVHSURYLGHXVZLWK\RXU7D[SD\HU,GHQWL¿FDWLRQ1XPEHU7,1

1.____________________________________ 2.____________________________________

 7D[SD\HU,GHQWL¿FDWLRQ1XPEHU 7D[SD\HU,GHQWL¿FDWLRQ1XPEHU

Are you a citizen of the United States?



Yes





Are you a citizen of the United States?



Yes



3/($6(,1',&$7(<285:,7++2/',1*(/(&7,21%<&+(&.,1*7+($335235,$7(%2;%(/2:

I elect to have the following withholding option applied to this payment and any future payments under this policy (please check only one box).

3OHDVH1RWH Non-natural owners (companies, corporations, trusts) cannot elect to have no withholding apply.



1R:LWKKROGLQJ

I elect to have no Federal or State Income taxes withheld from

this payment and from any future payments under this policy.



%RWK)HGHUDODQG6WDWH:LWKKROGLQJ

I elect to have both Federal and State income taxes withheld from

this payment and from any future payments under this policy.



)HGHUDO:LWKKROGLQJ2QO\

I elect to have Federal Income taxes withheld from this payment

and from any future payment. No State income taxes will be

withheld. (This option may not be available for residents of certain

states. See the State Income Tax Withholding section of this form.)



6WDWH:LWKKROGLQJ2QO\

I elect to have State income taxes withheld from this payment

and from any future payment. No Federal income taxes will be

withheld.

If you elected any of the options above in which taxes will be withheld, you can specify the tax withholding percentage (%) of each

ZLWKGUDZDO\RXZRXOGOLNHWRKDYHDSSOLHGWR)HGHUDODQGRUVWDWHLQFRPHWD[ZLWKKROGLQJ,IDVSHFL¿FWD[ZLWKKROGLQJDPRXQWLVQRWLQGLFDWHG

below, we will withhold 10% for federal tax purposes and the state’s minimum withholding (if applicable). 3OHDVHÀOOLQLWHPVDQG

(1) I would like to apply _______% of the taxable portion to Federal Withholding.

(2) I would like to apply _______% of the taxable portion to State Withholding.

If you elect to have Federal income tax withheld, we are required to withhold at least 10% of the taxable portion of the distribution. If your state

requires withholding, we will withhold the state’s minimum amount if you select an amount that is less than the minimum. Please see the Important

State Income Tax Withholding Information for more information.

21575 0520 07

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21575 (5/2020) Page 8 of 10

SECTION F AUTHORIZATION AND SIGNATURES

(YHQLI\RXDOUHDG\FRPSOHWHG6HFWLRQ&IRU()7SOHDVHFRQÀUP\RXUFXUUHQWDGGUHVVEHORZ

BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB

,I\RXGLGQRWFRPSOHWH6HFWLRQ&IRU()7SOHDVHFKHFNKHUH

 Please send my check to the address of record.

I, the policyowner, understand and agree that:

3DUWLDO:LWKGUDZDOVLQFOXGLQJ3HULRGLF3DUWLDO:LWKGUDZDOVPD\UHGXFHWKHGHDWKEHQH¿WSD\DEOHXQGHUWKHSROLF\

Distributions that are taxable will be reported to the IRS on Form 1099R.

It is the participant’s responsibility to meet the IRS requirements that qualify for this distribution.

The effective date of this request will be the date it is received in the Variable Products Service Center of New York Life Insurance and Annuity

Corporation (NYLIAC), completed with all required information for processing. See the instructions on page 1 for this address.

Once the withdrawal is processed, NYLIAC is not obligated to accept any return of the monies distributed.

Distributions that are paying a premium on another NYLIAC, New York Life Insurance Company, or Long Term Care policy will be sent directly

to the administrator of the policy number(s).

Under penalties of perjury, I (as owner named) certify:

0\VRFLDOVHFXULW\QXPEHURU7D[,'QXPEHUVKRZQRQWKLVIRUPLVP\FRUUHFWWD[SD\HULGHQWL¿FDWLRQQXPEHU

,DPQRWVXEMHFWWREDFNXSZLWKKROGLQJEHFDXVHD,DPH[HPSWIURPEDFNXSZLWKKROGLQJRUE,KDYHQRWEHHQQRWL¿HGE\WKH,56WKDW,

DPVXEMHFWWREDFNXSZLWKKROGLQJDVDUHVXOWRIDIDLOXUHWRUHSRUWDOOLQWHUHVWRUGLYLGHQGLQFRPHRUFWKH,56KDVQRWL¿HGPHWKDW,DPQR

longer subject to backup withholding,

I am a U.S. person (includes a U.S. resident alien), and

The FATCA code entered on this form (if any) indicating that I am exempt from FATCA reporting is correct. (Please note: if being submitted

IRUD86DFFRXQWWKLVODVWFHUWL¿FDWLRQGRHVQRWDSSO\

&KHFNWKLVER[LIWKH,56KDVQRWL¿HG\RXWKDW\RXDUHVXEMHFWWREDFNXSZLWKKROGLQJ,I,DPD86HQWLW\,DPVXEPLWWLQJDFRPSOHWHG,56

Form W-9. If I am not a U.S. citizen, U.S. resident alien or other U.S. person, I am submitting the applicable Form W8 with this form to certify my

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7KH,QWHUQDO5HYHQXH6HUYLFHGRHVQRWUHTXLUH\RXUFRQVHQWWRDQ\SURYLVLRQRIWKLVGRFXPHQWRWKHUWKDQWKHFHUWL¿FDWLRQVUHTXLUHGWRDYRLG

backup withholding.

Please Note:$OOVLJQDWRULHVPXVWSURYLGHWKHLU7D[SD\HU,GHQWL¿FDWLRQ1XPEHULQWKH,QFRPH7D[:LWKKROGLQJ(OHFWLRQVHFWLRQ

1.) Policyowner(s) Signature ; __________________________________________________________________ Date _________________

2.) Assignee or ;_____________________________________________________________________________ Date _________________

Other Required Signature

Policyowner(s) phone number (9am - 5pm eastern time) (________)________________________________________________________

,IWKHLQGLFDWHGSROLF\LVFRUSRUDWHRZQHGSURYLGHVLJQDWXUHVDQGWLWOHVRIWZRFRUSRUDWHRI¿FHUV

,IRQHLVQRWDOUHDG\RQ¿OHSOHDVHSURYLGHDFRUSRUDWHFKDUWHUWRLGHQWLI\WKHEHORZVLJQRUVDVDXWKRUL]HGLQGLYLGXDOV

3.) 6LJQDWXUHRI2I¿FHU; _______________________________________________________________________ Date _________________

 3ULQW1DPHRI2I¿FHU;___________________________________________________________________________________________

 2I¿FHU¶V7LWOHBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB

4.) 6LJQDWXUHRI2I¿FHU; _______________________________________________________________________ Date _________________

 3ULQW1DPHRI2I¿FHU;___________________________________________________________________________________________

 2I¿FHU¶V7LWOHBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB

21575 0520 08

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21575 (5/2020) Page 9 of 10

1RWDUL]HGFRQÀUPDWLRQRU0HGDOOLRQ6LJQDWXUH*XDUDQWHHUHTXLUHGIRUDPRXQWVJUHDWHUWKDQ

3ODFHQRWDU\FRQ¿UPDWLRQRU0HGDOOLRQ6LJQDWXUH*XDUDQWHHEHORZ

STATE OF _____________________________ COUNTY OF ___________________________

The foregoing instrument was acknowledged before me this ________ day of _____________, 20_____ by _________________, who is/are

personally known to me or satisfactorily proven to be the person who executed it for the purposes therein contained.

___________________________________________ _________________________________

Notary Public Name (Please print)

My commission expires:

21575 0520 09

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21575 (5/2020) Page 10 of 10

,03257$1767$7(,1&20(7$;:,7++2/',1*,1)250$7,21

<RXVKRXOGFRQVXOWZLWK\RXUSHUVRQDOWD[DGYLVRUSODQDGPLQLVWUDWRU6WDWHLQFRPHWD[DXWKRULW\RU\RXUORFDO,56RI¿FHLI\RXKDYH

DQ\TXHVWLRQVDERXWLQFRPHWD[ZLWKKROGLQJ,56SXEOLFDWLRQ7D[:LWKKROGLQJDQG(VWLPDWHG7D[DQG,56IRUPV:DQG:3

For residents of Arkansas, California, Delaware, Georgia, Iowa, Kansas, Maine, Maryland, Massachusetts, Nebraska, North Carolina,

Oklahoma, Oregon, Vermont , Virginia and Washington, DC: As of January 1, 2018, state withholding is generally required if federal income

tax is being withheld.

For residents of Arkansas, California, Georgia, Maine, North Carolina, Oregon, and Vermont: If federal income tax is being withheld, state

income tax withholding is generally required, unless you elect not to have state income tax withholding apply.

For residents of Michigan: We are required to withhold state income tax from the taxable portion of your payments, unless you provide us

with a properly completed Form MI W-4P and you claim an exemption from withholding.

For residents of Connecticut: We are required to withhold state income tax from the taxable portion of your payments, unless you provide

us with a properly completed Form CT-W4P and you claim an exemption from withholding. An exemption may not be claimed for lump sum

distributions.

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As of January 1, 2018, these states do not require withholding of state income taxes, but generally allow you to elect to have withholding apply.

Certain exceptions and special rules apply in some states.

)RUUHVLGHQWVRI$UL]RQD State income tax withholding is voluntary and only applies to periodic payments. Withholding election requests must

be accompanied by Arizona Form A-4P.

,03257$17)('(5$/,1&20(7$;:,7++2/',1*,1)250$7,21

This information is required to carry out the Internal Revenue laws of the United States and to provide you with some basic information about

ZLWKKROGLQJRI)HGHUDOLQFRPHWD[IURP\RXUSD\PHQWXQGHUWKHSROLF\VSHFL¿HGRQWKHIURQWRIWKLVIRUP

A partial withdrawal may result in a taxable gain reportable to the IRS. Generally, Federal withholding applies to payments made from pension,

SUR¿WVKDULQJVWRFNERQXVDQQXLW\DQGRWKHUHPSOR\HHGHIHUUHGFRPSHQVDWLRQSODQVLQGLYLGXDOUHWLUHPHQWDUUDQJHPHQWV,5$WD[VKHOWHUHG

annuities (TSA), and commercial annuities (which include individual annuity, life insurance and endowment policies). Federal income tax may

EHZLWKKHOGRQO\IURPWKHWD[DEOHSRUWLRQRI\RXUSD\PHQWDVGHWHUPLQHGIURPRXUUHFRUGVDWDÀDWUDWH

Federal income tax must be withheld unless you elect not to have withholding apply to the taxable portion of your payment. You can make this

election by checking the appropriate box in Section E, the INCOME TAX WITHHOLDING ELECTION section. Generally, your election as to

whether taxes are or are not to be withheld will apply to any other payment from the same policy. You may change this election at any time. To

change your previous election, check one of the boxes in Section E, the INCOME TAX WITHHOLDING ELECTION section.

Even if you elect not to have Federal income tax withheld, you are liable for the payment(s) of such tax on the taxable portion of your

payment(s). There are penalties under the estimated tax payment rules if enough tax has not been paid through either estimated tax payments

RUZLWKKROGLQJ7KHUHLVDQDGGLWLRQDOSHQDOW\WD[LPSRVHGE\WKH,56RQ³SUHPDWXUHGLVWULEXWLRQV´IURPDQQXLW\FRQWUDFWVDQGPRGL¿HG

endowment contracts, unless you are disabled or at least 59½ years of age at the time the withdrawal is made.

If the taxable portion of a payment when added to the taxable portion of all other payments during the year is less than $200, Federal income

WD[LVQRWUHTXLUHGWREHZLWKKHOG:HZLOOQRWZLWKKROG)HGHUDOLQFRPHWD[LIWKHSD\PHQWLVEHLQJPDGHWRWKH7UXVWHHVRIDTXDOL¿HGSHQVLRQRU

SUR¿WVKDULQJSODQ

Securities are offered by properly licensed registered representatives of NYLIFE Securities LLC, (member FINRA/SIPC),

a Licensed Insurance Agency, 51 Madison Avenue, New York NY 10010.

21575 0520 10

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