1
New York Life Insurance Company
New York Life Insurance and Annuity Corporation
(A Delaware Corporation)
51 Madison Avenue, New York, NY 10010
NYLIFE Insurance Company of Arizona*
(Not licensed in every state)
4343 North Scottsdale Road, Suite 220
Scottsdale, AZ 85251
Receiving the Annuity benets intended for you
Dear Beneficiary:
On behalf of New York Life, please accept our sincere condolences during this difficult time. In the
following pages, you will find the Death Benefit Proceeds Form to be completed and returned by you.
Please provide a copy of the death certificate with this form.
What to expect after you submit your claim
We are committed to processing your claim as quickly as possible. Once we receive complete claim
documents, if additional information is required, a customer service professional will contact you.
Payment of your claim
You will be mailed a check for your share of the proceeds unless you elect a settlement alternative
made available in the original annuity contract. Proceeds from annuity products will be credited with
interest as per the annuity contract.
We are here to help
For assistance in completing the form or understanding what information is required, you may contact
a local New York Life Agent or call a customer service professional at (800) CALL-NYL Monday through
Friday, 8 a.m. to 7 p.m. ET. Please say the word “Claims” at any time during the interactive menu to be
transferred directly to the Claims Department. In addition, you may find helpful bereavement information
on our website, www.newyorklife.com.
From all of us at New York Life and our 12,000 financial service professionals across the country, we
are here to be of service to you and your family. Just let us know how we can be of further assistance.
*NYLIFE Insurance Company of Arizona is not authorized in New York or Maine and does not conduct insurancebusiness in New York or Maine.
20838ANNUITY (4/2020)
20838ANNUITY 0420 01
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Information Regarding Your Annuity Payment Options and Settlement Alternatives
Unless settlement alternatives are available in the annuity contract and you choose one of these alternatives as described
below, you will be mailed a check for your share of the proceeds. Based on the annuity product, the proceeds may be a
continuation of income payments. Proceeds from an annuity contract may have taxable portions. Proceeds will be credited
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to pay the proceeds are received in good order.
Important Information
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account. What this means for you: When you open an account, we will ask for your name, address, date of birth, and other
information that will allow us to identify you. We may also ask to see your driver’s license or other identifying documents.
Settlement Alternatives - for Individual Beneciaries (See next page for trust, estate and corporation beneciaries)
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proceeds to you. Please refer to the original annuity contract for a description of any alternatives. If the annuity contract
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method of settling a claim. If this has been done, we are obligated to carry out those instructions and will give you full details.
If the annuity contract is not readily available, or for more information on these options, please contact New York Life at
(800) CALL-NYL and a customer service professional will be happy to help you. Please say the word “Claims” at any time
during the interactive menu to be transferred directly to the Claims Department.
A brief description of the settlement alternatives that may be available through the original annuity contract are provided below.
Proceeds Left on Deposit: Allows you to leave your settlement proceeds with the New York Life to earn interest. Please see
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you name will receive the remaining value in a check. This option is not tax deferred. Gain on the annuity contract is reported as
taxable the year in which your claim is processed.
Elected Income: Equal periodic payments are made according to one of the following methods, as chosen by you:
1) For an elected period of years ( 1 – 30 years) or 2) For an elected payment amount
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Income under this option must begin within one year of the date of death and the length of the payment period may not exceed
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Guaranteed Life Income: Equal periodic payments are made during your lifetime. You may be allowed to select guaranteed
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must begin within one year of the date of death and the length of the payment period may not exceed your life expectancy. If you
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no cash value and there are no additional withdrawals or loans permitted.
Surviving Spouse Option (Deferred Annuity Contracts Only): A surviving spouse may have certain rights if he or she is the sole
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paying taxes until he or she decides to make a withdrawal or surrender the annuity contract. The spouse assumes ownership of
the annuity contract at the current accumulation value and the existing surrender charge schedule.
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the annuity by checking the box on page 8. The annuity will then be registered in your name, and it will continue under the same
terms and conditions as the original annuity contract, including any existing surrender charge schedule. For more information
regarding tax consequences, please consult your tax advisor.
20838ANNUITY (4/2020)
20838ANNUITY 0420 02
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Continuation of Payments (Income Annuities & Supplementary Contracts Only): On income annuities, except in the case of
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for the remainder of the guaranteed period. To choose this option, select Continue Payments on page 8 and complete page 10.
If you would like your payments sent to a bank account, please provide a void check with your claim form or complete a direct
deposit form. Please noteRQWD[TXDOLƬHGLQFRPHDQQXLW\FRQWUDFWVXQOHVV\RXDUHDVSRXVHRURWKHU(OLJLEOH'HVLJQDWHG
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income period exceeds 10 years. Depending on the issue date of the original contract, the proceeds may have to be commuted
to a value equal to the present value of the future guaranteed payments.
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established. Please consult a tax and/or legal professional to determine if this option is available.
Settlement Alternatives - for trusts, estates and corporations
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contract makes no mention of these, the proceeds will be distributed in a check. In some cases, the policyowner may have
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you full details. For all of the information below, please consult your legal professional regarding the availability of options
based on the provisions of the Will or trust, as applicable. For more information regarding tax consequences, please consult
your tax advisor.
If the annuity contract is not readily available, or for more information on these options, please contact New York Life at
(800) CALL-NYL and a customer service professional will be happy to help you. Please say the word “Claims” at any time
during the interactive menu to be transferred directly to the Claims Department.
A brief description of the settlement alternatives that may be available through the original annuity contract are
provided below.
Elected Income: Equal periodic payments are made according to one of the following methods, as chosen by you:
1) For an elected period of years or 2) For an elected payment amount
On TXDOLƬHG annuity contracts, this Settlement Alternative option is only available to trusts. On QRQTXDOLƬHG annuity
contracts, this Settlement Alternative option is only available to trusts and estates.
This option must be selected within 1 year of the date of death and the payment period must end within 5 years of the
date of death.
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paperwork. This must be done as a trustee-to-trustee transfer where the check is sent directly to the custodian/institution
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Continuation of Payments (Income Annuities & Supplementary Contracts Only): If an entity such as a corporation, non-
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selected, then the corporation, non-grantor trust or estate must stay open for the remainder of the guaranteed period.
20838ANNUITY (4/2020)
20838ANNUITY 0420 03
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4
H-20250
Important Information about Proceeds Left on Deposit
For Individual Beneciaries (not available if the beneciary is a trust, corporation or estate)
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contract makes no mention of these, the proceeds will be distributed in a check.
This settlement alternative allows you to leave your settlement
proceeds with New York Life to earn interest. The interest can
be paid to you monthly, quarterly, semi-annually, or annually, or
you can choose to leave the interest on deposit with us. This
is not a tax deferred option. Any taxable gain on the annuity
contract will be reported as taxable in the year in which your
claim is processed.
This alternative may contain a Guaranteed Minimum Interest
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are issued. If the company’s declared interest rate, which is set
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be applied to the amount on deposit. The insurer may derive
income, in addition to any fees charged on the account, from
the total gains received on the investment of the balance
of funds.
Interest earned on proceeds left on deposit may be taxable.
You will receive a Form 1099-INT annually reporting the amount
of taxable interest. This form contains the amount of interest
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D)RUP5UHSRUWLQJWKHDPRXQWRIDQ\WD[DEOHJDLQ
3OHDVHFRQVXOW\RXUWD[LQYHVWPHQWRURWKHUƬQDQFLDODGYLVRU
regarding tax liability and investment options.
Proceeds or interest left on deposit can be withdrawn by
contacting us at (800) CALL-NYL. You will be connected with
RXU5HWLUHPHQW6ROXWLRQVWHDPWRDVVLVW\RXZLWK\RXUUHTXHVW
We may be able to process your request over the phone or
if you prefer send a withdrawal request form for completion.
If you provide us with your checking or savings account
information your funds will be sent to you electronically,
otherwise a check will be sent to your mailing address.
5HTXHVWVVXEPLWWHGLQZULWLQJVKRXOGEHVXEPLWWHGWRWKH
below address:
New York Life
PO Box 130539
Dallas, TX 75313-0539
If you leave the interest with us, the interest earned can
be withdrawn at any time in sums of $100 or more. The
principal can be withdrawn at any time, and when any partial
disbursements are made, accumulated interest is paid out
ƬUVW7KHPLQLPXPZLWKGUDZDODPRXQWLV7KHHQWLUH
proceeds are available to be withdrawn at any time. There are
no withdrawal penalties if the payee chooses to terminate
this settlement alternative. Other available settlement
alternatives, if applicable, are preserved until the entire
balance is withdrawn or until the balance drops below $2,000.
Proceeds or interest held in this settlement alternative will
remain with the New York Life Insurance Company that issued
the annuity contract. They will not be held in a bank. The funds
ZLOOEHJXDUDQWHHGE\WKHƬQDQFLDOVWUHQJWKRIWKHLQVXUHUIRU
as long as any proceeds or interest remain. These funds are
not guaranteed by the Federal Deposit Insurance Corporation
(FDIC).
If you choose this settlement alternative, please keep us
informed if you change your mailing address or wish to
ZLWKGUDZDOORI\RXUIXQGV5HWXUQHGPDLORUDFFRXQWLQDFWLYLW\
may require us under state law to treat your account as
unclaimed property and eventually release the funds to the
appropriate state. Please be assured that we will try to locate
you before releasing such funds. However, the best way to
maintain control of your funds is to promptly notify us of any
address change or of your intention to completely withdraw
your funds.
The insurer will comply with any valid governmental or
regulating authority’s order with respect to the funds,
including, but not limited to, court orders, liens, tax levies
or garnishments.
FOR FURTHER INFORMATION, PLEASE CONTACT YOUR STATE DEPARTMENT OF INSURANCE
20838ANNUITY 0420 04
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5
Important Federal Income Tax Withholding Information
7KLVLQIRUPDWLRQLVUHTXLUHGWRFDUU\RXWWKH,QWHUQDO5HYHQXHODZVRIWKH8QLWHG6WDWHVDQGWRSURYLGH\RXZLWKVRPH
basic information about withholding of Federal income tax from your payment under the annuity contract specified in
the Tax Withholding Election section.
$GLVEXUVHPHQWPD\UHVXOWLQDWD[DEOHJDLQUHSRUWDEOHWRWKH,56*HQHUDOO\)HGHUDOZLWKKROGLQJDSSOLHVWRWD[DEOH
payments made from pension, profit-sharing, stock bonus, annuity and other employer deferred compensation
SODQVLQGLYLGXDOUHWLUHPHQWDFFRXQWV,5$DQGFRPPHUFLDODQQXLWLHVZKLFKLQFOXGHLQGLYLGXDODQQXLW\OLIH
insurance and endowment policies). Please consult a professional tax advisor for more information on this tax and for
exceptions to this rule.
Federal income tax must be withheld at a 10% rate 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 the Tax Withholding Election section.
Non-persons such as corporations, companies, trusts, etc. or U.S. citizens living outside the United States cannot
elect out of withholding.
Important State Income Tax Withholding Information
for Individual Beneciaries (as of January 1, 2020)
For residents of Arkansas, California, Delaware, Georgia, Iowa, Kansas, Maine, Maryland, Massachusetts, Nebraska,
North Carolina, Oklahoma, Oregon, Vermont , Virginia and Washington, DC: 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 distributions made in a single sum.
For residents of Alabama, Colorado, Hawaii, Idaho, Illinois, Indiana, Kentucky, Louisiana, Minnesota, Mississippi,
Missouri, Montana, New Jersey, New Mexico, New York, North Dakota, Ohio, Pennsylvania, Rhode Island, South
Carolina, Utah, West Virginia and Wisconsin: 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.
For residents of Arizona: State income tax withholding is voluntary and only applies to periodic payments. Withholding
election requests must be accompanied by Arizona Form A-4P. Without an A-4P New York Life cannot withhold Arizona
state taxes if elected.
For residents of Alaska, Florida, Nevada, New Hampshire, South Dakota, Tennessee, Texas, Washington and Wyoming:
These states do not require withholding of state income taxes.
Important State Income Tax Withholding Information for corporations, trusts or estates
established in the following states (as of January 1, 2020)
Arkansas, California, Delaware, Georgia, Iowa, Kansas, Maine, Maryland, Massachusetts, Nebraska, North Carolina,
Oklahoma, Oregon, Vermont, Virginia and Washington, DC: State withholding is generally required if federal income tax
is being withheld.
Alabama, Arizona, Colorado, Connecticut, Hawaii, Idaho, Illinois, Indiana, Kentucky, Louisiana, Michigan, Minnesota,
Mississippi, Missouri, Montana, New Jersey, New Mexico, New York, North Dakota, Ohio, Pennsylvania, Rhode Island,
South Carolina, Utah, West Virginia and Wisconsin: 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.
Alaska, Florida, Nevada, New Hampshire, South Dakota, Tennessee, Texas, Washington and Wyoming: These states do
not require withholding of state income taxes.
State specific tax withholding requirements are subject to change. Certain states may require a state-specific W-4P
form. Please contact a tax professional or your state department of revenue for more information.
20838ANNUITY (4/2020)
20838ANNUITY 0420 05
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6
Helpful Hints for Completing the Death Benefit Proceeds Form
For the correct approach to complete the Death Benefit Proceeds Form based on your particular situation,
please contact a tax, legal or accounting professional or visit the IRS website: irs.gov, where you can review the
IRS Form W-9 instructions.
Important Information
An EIN/Taxpayer Identification Number (TIN) may be applied for on the IRS website: irs.gov.
If the individual responsible for filing the claim differs from the taxpayer, a Form W-9 may be required.
Types of trusts in general
Living trusts are established during the trust creator’s lifetime. A living trust can be revocable or irrevocable. A living
trust may be considered either a grantor trust or a non-grantor trust for federal income tax purposes.
Grantor trusts are trusts whose separate identity is ignored for federal income tax purposes and whose income is
taxable directly to the grantor/creator of the trust. Although there are exceptions, a grantor trust generally does not
have an EIN/TIN or file its own tax return. A grantor trust generally becomes a non-grantor trust after the grantor’s
death.
Non-grantor trusts are trusts who have a separate identity for federal income tax purposes and are required to obtain
its own EIN/TIN and file its own tax return.
Testamentary trusts are established after the creators death, typically through the creator’s Will, which must be
probated.
If the beneficiary is a non-grantor trust
,IWKHWUXVWLVWUHDWHGDVDQRQJUDQWRUWUXVWWKH,56UHTXLUHVWKHQDPHDQG(,17,1RIWKHWUXVWWREHSURYLGHG
If the beneficiary is a grantor trust
The deceased Insured’s Social Security Number (SSN) cannot be used. A SSN is typically acceptable for a grantor
trust that has a living grantor (or surviving grantor).
,IWKHWUXVWLVFXUUHQWO\WUHDWHGDVDJUDQWRUWUXVWLQPRVWVLWXDWLRQVWKH,56UHTXLUHVWKHJUDQWRUWRSURYLGHKLVRU
KHUQDPHDQG661DQGWRVLJQWKH'HDWK%HQHILW3URFHHGV)RUPLIDOVRWUXVWHH6HH,56)RUP:LQVWUXFWLRQVIRU
VLWXDWLRQVZKHQWKH,56UHTXLUHVWKH(,17,1DQGQDPHRIWKHJUDQWRUWUXVWWREHSURYLGHG
If the beneficiary is an estate
The deceased Insured’s SSN cannot be used.
,IWKHEHQHILFLDU\LVDQHVWDWHWKH,56UHTXLUHVWKHQDPHDQG(,17,1RIWKHHVWDWHWREHSURYLGHG
If the estate has not and will not be probated, please contact the probate court in the county where the deceased
resided to determine if the estate falls under their small estate guidelines. If you are claiming as heir or affiant and you
have provided the relevant documentation establishing your rights to receive payment, please complete Section 3A
of the Death Benefit Proceeds Form using your individual information and SSN.
Neither New York Life Insurance Company, nor its agents, provide tax, legal, or accounting advice. Please consult your own tax, legal, or
accounting professional before making any decisions.
Questions? Call (800) CALL-NYL 8am – 7pm ET
20838ANNUITY (4/2020)
This is our understanding of the Federal Tax laws. Neither New York Life nor its agents provide tax, legal or accounting advice.
20838ANNUITY 0420 06
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7
State Variations of Fraud Warnings
Kindly refer to the applicable fraud warnings for your state of residence.
Arizona For your protection Arizona law requires the
following statement to appear on this form. Any person
who knowingly presents a false or fraudulent claim for
payment of a loss is subject to criminal and civil penalties.
California For your protection California law requires
the following to appear on this form: Any person who
knowingly presents a false or fraudulent claim for the
payment of a loss is guilty of a crime and may be subject to
ƬQHVDQGFRQƬQHPHQWLQVWDWHSULVRQ.
Colorado It is unlawful to knowingly provide false,
incomplete, or misleading facts or information to an
insurance company for the purpose of defrauding or
attempting to defraud the company. Penalties may
LQFOXGHLPSULVRQPHQWƬQHVGHQLDORILQVXUDQFHDQGFLYLO
damages. Any insurance company or agent of an insurance
company who knowingly provides false, incomplete,
or misleading facts or information to a policyholder or
claimant for the purpose of defrauding or attempting
to defraud the policyholder or claimant with regard to a
settlement or award payable from insurance proceeds
shall be reported to the Colorado Division of Insurance
within the department of regulatory agencies.
District of Columbia Any person who knowingly presents
DIDOVHRUIUDXGXOHQWFODLPIRUSD\PHQWRIDORVVRUEHQHƬW
or knowingly presents false information in an application
for insurance is guilty of a crime and may be subject to
ƬQHVDQGFRQƬQHPHQWLQSULVRQ
Florida Any person who knowingly and with intent to
LQMXUHGHIUDXGRUGHFHLYHDQ\LQVXUHUƬOHVDVWDWHPHQWRI
claim or an application containing any false, incomplete,
or misleading information is guilty of a felony of the third
degree.
Maryland Any person who knowingly or willfully
presents a false or fraudulent claim for payment of a loss
RUEHQHƬWRUZKRNQRZLQJO\RUZLOOIXOO\SUHVHQWVIDOVH
information in an application for insurance is guilty of a
FULPHDQGPD\EHVXEMHFWWRƬQHVDQGFRQƬQHPHQWLQ
prison.
New Jersey$Q\SHUVRQZKRNQRZLQJO\ƬOHVD
statement of claim containing any false or misleading
information is subject to criminal and civil penalties.
New York Any person who knowingly and with intent
to defraud any insurance company or other person
ƬOHVDQDSSOLFDWLRQIRULQVXUDQFHRUVWDWHPHQWRIFODLP
containing any materially false information, or conceals
for the purpose of misleading, information concerning
any fact material thereto, commits a fraudulent
insurance act, which is a crime, and shall also be subject
WRDFLYLOSHQDOW\QRWWRH[FHHGƬYHWKRXVDQGGROODUVDQG
the stated value of the claim for each such violation.
Oregon Any person who knowingly and with intent
to defraud any insurance company or other person
ƬOHVDQDSSOLFDWLRQIRULQVXUDQFHRUVWDWHPHQWRIFODLP
containing any materially false information or conceals,
for the purpose of misleading, information concerning
any fact material thereto may be subject to prosecution
for insurance fraud. Any person who provides mis-
information material to the content of the contract,
which is relied upon by the insurer, and which is either
material to the risk assumed by the insurer or provided
fraudulently, may be subject to the denial of insurance
EHQHƬWV
Pennsylvania Any person who knowingly and with
intent to defraud any insurance company or other person
ƬOHVDQDSSOLFDWLRQIRULQVXUDQFHRUVWDWHPHQWRIFODLP
containing any materially false information or conceals
for the purpose of misleading, information concerning
any fact material thereto commits a fraudulent insurance
act, which is a crime and subjects such person to criminal
and civil penalties.
Puerto Rico Any person who knowingly and with the
intention of defrauding presents false information in
an insurance application, or presents, helps, or causes
the presentation of a fraudulent claim for the payment
RIDORVVRUDQ\RWKHUEHQHƬWRUSUHVHQWVPRUHWKDQ
one claim for the same damage or loss, shall incur a
felony and, upon conviction, shall be sanctioned for
HDFKYLRODWLRQZLWKWKHSHQDOW\RIDƬQHRIQRWOHVV
WKDQƬYHWKRXVDQGGROODUVDQGQRWPRUHWKDQ
WHQWKRXVDQGGROODUVRUDƬ[HGWHUPRI
imprisonment for three (3) years, or both penalties.
Should aggravating circumstances be present, the
penalty thus established may be increased to a
PD[LPXPRIƬYH\HDUVLIH[WHQXDWLQJFLUFXPVWDQFHV
are present, it may be reduced to a minimum of
two (2) years.
Other States Any person who knowingly and with the
intent to defraud any insurance company or other person
ƬOHVDQDSSOLFDWLRQIRULQVXUDQFHRUVWDWHPHQWRIFODLP
containing any materially false information, or conceals,
for the purpose of misleading, information concerning
any fact material thereto, commits a fraudulent
insurance act, which is a crime and subjects such person
to criminal and civil penalties. Penalties may include
LPSULVRQPHQWƬQHVRUDGHQLDORILQVXUDQFHEHQHƬWV
if a person provides false information.
23442 (5/2018)
20838ANNUITY 0420 07
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PAGE LEFT INTENTIONALLY BLANK
20838ANNUITY 0420 08
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1
Death Benet Proceeds Form - Annuity
8
Continue to page 10 Tax Withholding Options and Signature
Social Security Number
5HODWLRQVKLS
Spouse
Child
Grandchild
Parent
Sibling
Other
Name Social Security
Number
FIRST M.I. LAST
Name Date
of birth
FIRST M.I. LAST
MM DD YYYY
1
List the policy number(s) or claim number under which you are making a claim
.
2
Provide information about the deceased.
Cause/ Date
manner of birth
of death
MM DD YYYY
Natural (type of illness or disease - check one) If not natural (check one)
Cancer
Heart disease
Accident
Suicide
5HVSLUDWRU\GLVHDVH
Homicide
Unknown
Other
Other
3
3URYLGHLQIRUPDWLRQDERXWWKHEHQHƬFLDU\(DFKEHQHƬFLDU\PXVWFRPSOHWHWKHLURZQIRUP
3A
,QGLYLGXDO%HQHƬFLDU\
––
,I\RXDUHDQLQGLYLGXDOEHQHƬFLDU\FRPSOHWH6HFWLRQ$,I\RXDUHFODLPLQJRQEHKDOIRIDWUXVWHVWDWHFRUSRUDWLRQFRQWLQXHWR6HFWLRQ%
5HVLGHQWLDO 
address
STREET APT. CITY S TAT E ZIP
Mailing
address
LIGLƪHUHQW
STREET APT. CITY S TAT E ZIP
Preferred Is this a cell phone? Email
phone no.
Ye s
No
,QFRPH7D[&HUWLƬFDWLRQ5HTXLUHG
If no selection is made, proceeds will be distributed as a check (if applicable).
Check A check for the proceeds will be mailed. Proceed to page 10.
Settlement Alternatives CHECK ONE. Only available for Deferred Annuities.
Important: Please see additional information on page 2 regarding which Settlement Alternatives are available to you.
Proceeds Left on Deposit - Complete page 10 and the Settlement Alternatives Election Form. This is not a tax deferred option.
Elected Income – Complete page 10 and the Settlement Alternatives Election Form.
Guaranteed Life Income - Complete page 10 and the Settlement Alternatives Election Form.
Spousal Continuance – This is not available on Tax Sheltered Annuities, or annuity contracts issued to Keogh Plans or Pension Plans.
I am the surviving spouse and sole primary beneficiary of the annuity contract(s). I wish to continue the annuity contract(s) and defer taxes.
I understand that by electing this option, no death benefit will be paid. Proceed to page 10, if elected. This option is available on Deferred
Annuities only. Not available in certain states.
Continue Payments – Continue the scheduled payments on the annuity contract (Income Annuities only, if applicable).
Proceed to page 10.
Inherited IRA / Transfer – Include any relevant transfer paperwork, letter of acceptance and the name of the receiving company (if not
New York Life) in the space provided and proceed to page 10.
Other
Payment of proceeds. Refer to page 2 for a description of the options/alternatives for which you may be eligible.
20838ANNUITY (4/2020)
20838ANNUITY 0420 09
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For more information, please see page 6
titled +HOSIXO+LQWVIRU&RPSOHWLQJWKH
'HDWK%HQHILW3URFHHGV)RUP.
5HVLGHQWLDO 
address
STREET APT. CITY S TAT E ZIP
Mailing
address
LIGLƪHUHQW
STREET APT. CITY S TAT E ZIP
Preferred Is this a cell phone? Email
phone no.
Ye s
No
Date of trust State where trust Is this a grantor trust for federal Is there a surviving grantor?
agreement was established income tax purposes?
Yes
No
Yes
No
MM DD YYYY
If no selection is made, proceeds will be distributed as a check (if applicable).
Check A check for the proceeds will be mailed. Proceed to page 10.
Settlement Alternative: Only available on deferred annuity contracts. Please see additional information on page 3 regarding which
Settlement Alternative options are available to you.
Income must begin within 1 year of the Date of Death and must end within 5 years of the Date of Death.
Elected Income for
years
Select a Frequency
Monthly
Quarterly
Semi-annually
Annually
3URFHHGWRSDJH
Inherited IRA / Transfer – Include any relevant transfer paperwork, letter of acceptance and the name of the receiving company (if not
New York Life) in the space provided and proceed to page 10.
Continue Payments: Continue the scheduled payments on the annuity contract (Income Annuities only, if applicable). Please consult
a tax and/or legal professional to determine if the trust, estate or corporation allows for payment continuation. Proceed to page 10.
Other
Payment of proceeds. Refer to page 3 for a description of the settlement options/alternatives for which you may be eligible.
9
3B
7UXVW(VWDWH&RUSRUDWLRQ%HQHƬFLDU\
Corporate Officer
(VWDWH5HSUHVHQWDWLYH
Trustee
Collateral Assignee
Other
Capacity under which you are making this claim CHECK ONE.
Death Benet Proceeds Form - Annuity (continued)
Continue to page 10 Tax Withholding Options and Signature
20838ANNUITY (4/2020)
Entity name as shown on income tax return (e.g. Name of trust, estate of deceased individual, corporation name, etc.)
Name of representative/trustee
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'HFHDVHGLQGLYLGXDOoV661FDQQRWEHXVHG
,QFRPH7D[&HUWLƬFDWLRQ5HTXLUHG
20838ANNUITY 0420 10
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1
Death Benet Proceeds Form - Annuity (continued)
3DUW$s6SHFLƬHG:LWKKROGLQJ(OHFWLRQ – Complete if you elected CHECK, CONTINUE PAYMENTS or SETTLEMENT ALTERNATIVES.
NO Federal or State taxes will be withheld.
BOTH Federal and State taxes will be withheld.
I would like to apply
% of the Taxable Portion to I would like to apply % of the Taxable Portion to
Federal Withholding.)HGHUDOPLQLPXPZLWKKROGLQJZLOODSSO\ to State Withholding. 0LQLPXPUHTXLUHGVWDWHZLWKKROGLQJZLOODSSO\
ONLY Federal taxes withheld.
I would like to apply
% of the Taxable Portion to Federal Withholding. Not available in certain states.
Please see page 5. )HGHUDOPLQLPXPZLWKKROGLQJZLOODSSO\
ONLY State taxes withheld. I would like to apply % of the Taxable Portion to
State Withholding. 0LQLPXPUHTXLUHGVWDWHZLWKKROGLQJZLOODSSO\
Part B – Complete ONLY if you elected CONTINUE PAYMENTS or SETTLEMENT ALTERNATIVES AND would like NYL to determine the tax withholding.
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minimum federal and state requirements.
Allowances: Total Number of allowances and marital status you’re claiming for withholding from each periodic annuity payment:
Single
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Married
Additional Amount: Provide additional amount, if any, you want withheld from each periodic annuity payment:
FEDERAL $
25 % STATE (if applicable) $ 25 % (minimum required federal & state withholdings will apply)
10
Questions? Call (800) CALL-NYL 8am – 7pm ET
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Any person who knowingly and with intent to defraud any insurance company or other person, files an application for insurance or statement of claim con-
taining any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent
insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such
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Under penalties of perjury, I (as beneficiary named) certify that: (1) my Social security number or Tax ID number shown on this death benefit proceeds
form is my correct taxpayer identification number, (2) I am not subject to backup withholding because: (a) I am exempt from backup withholding; or (b) I
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notified me that I am no longer subject to backup withholding, (3) I am a U.S. person (includes a U.S. resident alien), and (4) the FATCA code entered on this
form (if any) indicating that I am exempt from FATCA reporting is correct. (Please note: If being submitted for a U.S.
annuity contract
, this last certification
(4) does not apply.)
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If I am not a U.S. citizen, U.S. resident alien or other U.S. person, I am submitting the applicable Form W-8 with this form to certify my foreign status
and, if applicable, claim treaty benefits.
The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding.
Mail: New York Life, Claims & Benefits, PO Box 130539, Dallas, TX 75313-0539
Overnight mail: New York Life, Claims & Benefits, 4849 Greenville Ave, Suite 700, Dallas TX 75206-4187
Title Name
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Title Name
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20838ANNUITY (4/2020)
Individuals must provide your Social Security Number and elect withholding options (below) to avoid default Federal Withholding. Amounts will
not be refunded by New York Life. If your state requires a separate W-4P form, that form may be required to complete the claim processing.
If you elect to have Federal income tax withheld, we are required to withhold at least 10% of the taxable portion of the distribution. Federal income
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Annuity (TSA) retirement plans.
Only grantor trusts with a surviving grantor, estates and tax exempt organizations may elect out of withholding. Corporations, companies,
non-grantor trusts, or U.S. citizens living outside the United States cannot elect out of withholding.
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4:
Tax Withholding Section
20838ANNUITY 0420 11
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1
Settlement Alternatives Election Form
11
20838SA (4/2020)
List the policy number(s) or claim number
.
Monthly
Quarterly
Semi-Annually
Annually
Elected Income 5HFHLYHHTXDOSHULRGLFSD\PHQWVIRUDVSHFLILFJXDUDQWHHGSHULRG
You may choose either the number of years or the payment amount. Please select one of the following.
I’d like to receive payments for years (1-30 years)
I’d like to receive payments in the amount of $ (duration of payout determined by dollar indicated)
Guaranteed Life Income5HFHLYHHTXDOSHULRGLFSD\PHQWVIRU\RXUOLIHWLPHZLWKJXDUDQWHHGSHULRG
Please select a 3D\PHQW*XDUDQWHH3HULRG (choose one):
5 years 10 Years 15 Years 20 Years
Guaranteed Total Amount - Guarantee payments for the greater of your lifetime or until the total amount paid equals the amount placed under
the contract.
1. Settlement Alternative Election
2. Frequency at which you wish to receive disbursements - IRU,QGLYLGXDOVRQO\
Mail: New York Life, Claims & Benefits, PO Box 130539, Dallas, TX 75313-0539
Overnight mail: New York Life, Claims & Benefits, 4849 Greenville Ave, Suite 700, Dallas TX 75206-4187
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3. 1DPHD%HQFLDU\sCOMPLETE ONLY if you selected a Settlement Alternative
Class:
Check one
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P Primary
S Secondary
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if the primary is
predeceased)
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Tax ID
MM DD YYYY
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Full Name (first name, middle name, last name) or name of trust/corporation Percentage
P Primary
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MM DD YYYY
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P Primary
S Secondary
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if the primary is
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Tax ID
MM DD YYYY
Address
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STREET APT. CITY S TAT E ZIP
Full Name (first name, middle name, last name) or name of trust/corporation Percentage
20838ANNUITY 0420 12
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