18484 (05/2021) 1
Periodic Partial Withdrawal/
Partial Withdrawal Request Form
If you are using the funds from this policy to purchase/fund another policy, please consider all aspects of the transaction before making a final
decision to ensure that it is in your best interest. The withdrawal of these funds may affect the guaranteed and non-guaranteed values, including
the accumulation amount and surrender value of the policy from which the funds are being released.
If your policy is a Tax Sheltered Annuity use form 18484T.
New York Life Variable Annuities
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 be effective as of the date on which we receive a complete resubmission.
For policies that have elected the Investment Protection Plan Rider (IPP), Investment Protection Plan II Rider (IPP II), Guaranteed Investment Protection
Rider (GIPR), Guaranteed Investment Protection Rider 2.0 (GIPR 2.0), Investment Preservation Rider (IPR), Investment Preservation Rider 2.0 (IPR 2.0),
Investment Preservation Rider (IPR 3.0), Investment Preservation Rider (IPR 4.0) or Annual Death Benefit Reset (ADBR) Rider, all partial withdrawals will
reduce the amount guaranteed under the rider on a proportional basis. Please see your product prospectus for more information.
Partial withdrawals may reduce the death benefit of your policy. Please see your product prospectus for more information.
Periodic Partial Withdrawal (PPW) arrangements are not available for New York Life Income Plus or Income Plus Variable Annuity II Policies with the
Guaranteed Future Income Benefit (GFIB) if the GFIB Payments have not been fully funded.
Please note that any PPW arrangement on your policy will be suspended when a Future Income Purchase (FIP) transaction is processed.
To process a Periodic Partial Withdrawal (PPW) arrangement, NYLIAC must receive this form at least five business days before the date the withdraw
-
als are to begin. The withdrawals will be effective on the day of the month you specify. If the day of the month specified is within five days of NYLIAC’s
receipt of this form, then the withdrawals will begin on the day specified in the following month. Please read the product prospectus for further
details regarding Partial Withdrawals and Periodic Partial Withdrawals (PPW).
Policy Policy owner name
number
STEP
1
Tell us your policy information.
Preferred Is this a cell phone? Email
phone no.
Ye s
No
Address
Check this box to update our records with this information.
STREET APT. CITY S TAT E ZIP
A PPW arrangement or partial withdrawal may result in a surrender charge being deducted, if the amount withdrawn, when added to the amount of
all prior surrender charge free withdrawals occurring during the current policy year, exceeds the greatest of (a) 10% of the current Accumulation
Value of your policy, (b) 10% of the Accumulation Value as of the prior Policy Anniversary (10% of the Premium Payment if the withdrawal is made
in the first policy year) or (c) the Accumulation Value less the accumulated premium payments. Please refer to a current product prospectus for
complete details. Any PPW arrangement or partial withdrawal from a New York Life Variable Annuity or New York Life Essentials Variable
Annuity Fixed account or DCA Advantage Plan Account will void the Fixed Account Initial Premium Guarantee. All policies may not be available
in all jurisdictions.
IMPORTANT TAX INFORMATION: If you withdraw funds from your New York Life IRA and plan to redeposit the funds into any IRA, please be aware
that you are allowed to make only one rollover from an IRA to another IRA in any 12-month period, regardless of the number or types of IRAs you
own. If you redeposit the funds into a New York Life IRA, you certify that: (1) the contribution qualifies as a rollover contribution pursuant to Internal
Revenue Code section 408(d)(3) and the applicable regulations, (2) you made the rollover contribution within 60 days after the day you received
the funds, and (3) including the rollover contribution, you have not made more than one indirect (i.e., 60 day) rollover from an IRA to another (or the
same) IRA in the previous 12 months regardless of the number or type of IRAs you own. If any of the above information is not correct, you will notify
New York Life within 30 days of the date of the rollover contribution.
The minimum amount that may be withdrawn is $500. With the exception of New York Life Flexible Premium Variable Annuities investing in
NYLIAC Variable Annuity Separate Accounts I and II, we will not process your partial withdrawal request if honoring such a request would result
in an Accumulation Value of less than $2,000.
Please Note: If you have a current and active 72(t) SEPP arrangement on your policy, requesting any partial withdrawal option below may result in a
modification of your 72(t) SEPP arrangement and the imposition of the 10% IRS penalty tax on all prior distributions, plus interest. You should consult
your tax advisor before making any changes to your 72(t) SEPP arrangement. Partial withdrawal requests for amounts greater than $50,000 must
include a notarized confirmation or Medallion Signature Guarantee of the policy owner’s signature.
Choose one option:
I wish to have $ (Gross) deducted from my policy. I understand that I may receive less than this amount if I elect to have
taxes withheld and/or a surrender charge applies.
I wish to receive $ (Net). I understand that the amount deducted from my policy may be greater if I elect to have taxes
withheld and/or a surrender charge applies.
I wish to withdraw 10% of the current Accumulation Value of my policy. I understand this withdrawal may be subject to a surrender charge if this is
QRWWKHƬUVWZLWKGUDZDO,KDYHPDGHGXULQJWKHFXUUHQWSROLF\\HDU
I wish to withdraw the gain in my policy (calculated as the Accumulation Value less the accumulated premium payments).
I wish to withdraw the maximum amount that is not subject to surrender charges.
I wish to withdraw the maximum amount available without terminating my policy. I understand this withdrawal may be subject to surrender charges.
STEP
2 Partial Withdrawal (One-time only)
Continued on the next page.
18484 0521 01
Print...
Next >
WY
18484 (05/2021) 2
3
)RU1HZ<RUN/LIH/RQJHYLW\%HQHƬW9DULDEOH$QQXLW\SROLF\RZQHUV21/< please consider the following provision when selecting a partial
withdrawal. Please indicate below, which option you direct NYLIAC to follow in the event that your partial withdrawal request reduces the
percentage of the premium payment invested in the investment divisions (at the time the distribution is made) to less than 25% of the
amount of the premium payment.
NYLIAC will adjust the amount of the partial withdrawal request such that the percentage of the premium payment invested in the
investment divisions (at the time the distribution is made) is not reduced below 25% of the premium payment.
I agree to surrender the policy for its Accumulation Value less any applicable fees and charges. Please complete the Income Tax
Withholding section to surrender the policy.
STEP
2 Continued from previous page
Continued on the next page.
)RU1HZ<RUN/LIH,QFRPH3OXVDQG,QFRPH3OXV9DULDEOH$QQXLW\,,3ROLF\KROGHUVZLWKWKH*XDUDQWHHG)XWXUH,QFRPH%HQHnjW*),%3DUWLDO
withdrawals taken before your GFIB Payments are fully funded will lower your GFIB Payments. Please consult your Registered Representative
before taking a Partial Withdrawal.
,IDQ\RIWKHVHSDUWLDOZLWKGUDZDORSWLRQVLQFOXGHPRQLHVWREHZLWKGUDZQIRUWKHSXUSRVHVRISD\LQJDSUHPLXPIRUDQRWKHU1</,$&
1HZ<RUN/LIH,QVXUDQFH&RPSDQ\RUD/RQJ7HUP&DUHSURGXFWSOHDVHLQGLFDWHWKHSROLF\QXPEHUDQGSD\PHQWW\SH3OHDVH1RWH
/RDQ5HSD\PHQWVDUHQRWHOLJLEOHIRU/RQJ7HUP&DUHSURGXFWV
7KHSDUWLDOZLWKGUDZDOZLOOEHXVHGWRSD\WKHSUHPLXPV
RQWKHIROORZLQJSROLF\QXPEHU
3UHPLXPSD\PHQWW\SHFKHFNRQH
Scheduled Premium Payment
Additional Premium Payment
Loan Repayment
Only one PPW arrangement may exist for each policy. If a new election form is received by NYLIAC, it will cancel any previous election form.
You may not elect to receive PPWs if you are currently making scheduled deposits to your policy via automatic deposits from your bank or
through a billing arrangement with your employer. PPWs will continue until notification to terminate them is received by NYLIAC.
For New York Life Longevity Benefit Variable Annuity policy owner(s), please consider the following provision when selecting a PPW
arrangement. If any PPW arrangement reduces the percentage of the premium payment invested in the investment divisions (at the time
the distribution is made) to less than 25% of the amount of the premium payment, the PPW arrangement will be terminated. We will notify
you if the termination of your PPW arrangement becomes necessary.
For New York Life Income Plus and Income Plus Variable Annuity II policies, PPW arrangements are not available with the Guaranteed Future
Income Benefit (GFIB) if the GFIB Payments have not been fully funded.
PPWs are not permitted from the DCA Advantage Plan Accounts.
*For any PPW arrangement selected, please be sure to indicate the frequency you wish to receive payments and the start date.
STEP
3 Periodic Partial Withdrawal (PPW - recurring withdrawals)
$6SHFLƬHG$PRXQW0LQLPXP $ (The requested amount will be withdrawn for each payment.)
Choose one option:
Gross: I understand that I may receive less than this amount if I elect to have taxes withheld and/or a surrender
charge applies.
Net:,ZLVKWRUHFHLYHWKHIXOODPRXQWVSHFLƬHGDERYH,XQGHUVWDQGWKDWWKHDPRXQWGHGXFWHGIURPP\SROLF\
may be greater if I elect to have taxes withheld and/or a surrender charge applies.
A Percent of Current Accumulation Value %.(The amount of each modal withdrawal will be a percentage of
accumulation value selected on the date of each payment; divided by the number of payments to be made during a 12-month period.)
Interest Only (Minimum Fixed Account(s) Value $5,000). Use this option to withdraw, from the Fixed Account(s), the interest earned on
monies allocated to the Fixed Account(s). If this option is chosen, skip Step 4. (If the Fixed Account Interest Sweep feature is being used,
electing this option will automatically cancel it.) This option is not available for New York Life Access Variable Annuity policies.
The Required Minimum Distribution (RMD.) This is the amount that is generally required by the Internal Revenue Service (IRS) to be
withdrawn annually from your Individual Retirement Annuity (IRA) policy once you reach age 72. (The distribution amount will be the
annual RMD amount for the annuity policy divided by the chosen frequency.) If this option is chosen, the RMD payment may be subject to
a surrender charge. Please select one option below:
Uniform Distribution Period: This calculation is the same for all individuals of the same age, regardless of the age or existence
RIDEHQHƬFLDU\7KH8QLIRUP/LIHWLPHWDEOHLVXVHGIRUWKLVFDOFXODWLRQ
Joint Life Expectancy:<RXDUHHOLJLEOHIRUWKLVRSWLRQRQO\LI\RXUVSRXVHLVWKHVROHEHQHƬFLDU\DQGKHRUVKHLVPRUHWKDQ
10 years younger than you. You must indicate the name, date of birth and the Social Security number of your spouse.
72(t) Substantially Equal Periodic Payments (SEPPs). This is the amount that you may withdraw from your Individual Retirement Annuity
(IRA) policy before you reach age 59½ without incurring the IRS 10% premature distribution penalty tax. SEPPs generally must continue
for at least 5 years or until you reach age 59½, whichever is later, and during this time you may not make a contribution to your policy or
RWKHUZLVHPRGLI\\RXU6(33DUUDQJHPHQW,I\RXU6(33VDUHPRGLƬHGRWKHUWKDQGXHWRGHDWKRUGLVDELOLW\EHIRUH\HDUVRUXQWLO\RXUHDFK
age 59½, whichever is later, the 10% penalty tax will be imposed retroactively on all prior distributions, plus interest. You should consult
your tax advisor before making any changes to your series of SEPP arrangement.
3A: Tell us how much you would like to receive for the scheduled withdrawals (Check only one)
Spouse’s name Spouse’s date of birth Spouse’s Social Security number
18484 0521 02
Print...
Next >
< Back
18484 (05/21) 3
4
Continued on the next page.
,I\RXEHJLQGLVWULEXWLRQVLQD\HDUXVLQJHLWKHUWKHƬ[HGDPRUWL]DWLRQPHWKRGRUWKHƬ[HGDQQXLWL]DWLRQPHWKRG\RXPD\LQDQ\VXEVHTXHQW
year switch to the RMD method to determine the payments for the year of the switch and all subsequent years. Once a change is made, the
RMD method must be followed in all subsequent years.
Surrender Charges will be waived on PPWs made pursuant to Section 72(t)(2)(A)(iv) of the Internal Revenue Code.
To elect one of the Fixed payment options, you must provide one of the following: either a copy of the NYLIAC illustration from your
agent, or a SEPP calculation letter from your tax advisor.
Please check one of the following 72(t) methods if you have selected the 72(t) arrangement:
Required Minimum Distribution (RMD) Method: NYLIAC will calculate the annual payment for each year by dividing the account balance
as of the preceding December 31st, by the appropriate number from the IRS Uniform Lifetime table. Under this method, the account
balance, the number from the IRS Uniform Lifetime table and the resulting annual payment is redetermined each year.
*Please note that there are other IRS-approved life expectancy tables, but NYLIAC uses only the IRS Uniform Lifetime table for purposes
of calculating SEPPs under the RMD method.
7KHƬ[HGDPRUWL]DWLRQPHWKRG7KHDQQXDOSD\PHQWIRUHDFK\HDULVGHWHUPLQHGE\DPRUWL]LQJLQOHYHODPRXQWVWKHDFFRXQWEDODQFH
RYHU\RXUOLIHH[SHFWDQF\RUWKHMRLQWOLIHH[SHFWDQF\RI\RXDQG\RXUEHQHƬFLDU\XVLQJWKHFKRVHQLQWHUHVWUDWH8QGHUWKLVPHWKRG
the account balance, the number from the chosen IRS life expectancy table and the resulting annual payment are determined once for
WKHƬUVWGLVWULEXWLRQ\HDUDQGWKHDQQXDOSD\PHQWLVWKHVDPHDPRXQWLQHDFKVXEVHTXHQW\HDU
Please provide the dollar amount $
. (The requested amount will be withdrawn each year.)
IRS life expectancy tables can be found in IRS Publication 590 and IRS Revenue Ruling 2002-62. You can choose any interest rate that is not more
than 120% of the federal mid-term rate for either of the two months immediately preceding the month in which you will start taking SEPPs.
7KHƬ[HGDQQXLWL]DWLRQPHWKRG The annual payment for each year is determined by dividing the account balance by an annuity factor
WKDWLVWKHSUHVHQWYDOXHRIDQDQQXLW\RIRYHU\RXUOLIHH[SHFWDQF\RUWKHMRLQWOLYHVRI\RXDQG\RXUEHQHƬFLDU\8QGHUWKLVPHWKRG
RQFHWKHDQQXDOSD\PHQWLVGHWHUPLQHGIRUWKHƬUVWGLVWULEXWLRQ\HDUWKHDQQXDOSD\PHQWUHPDLQVWKHVDPHLQHDFKVXEVHTXHQW\HDU
Please provide the dollar amount $
. (The requested amount will be withdrawn each year.)
The annuity factor is derived using the mortality table in Appendix B of IRS Revenue Ruling 2002-62 and the chosen interest rate. You can
choose any interest rate that is not more than 120% of the federal mid-term rate for either of the two months immediately preceding the
month in which you will start taking SEPPs.
If any of these PPW options include 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 periodic partial withdrawal will be used to
pay the premiums on the following policy number:
3A: Continued from previous page
Monthly
Quarterly
Semi-Annually
Annually
Payment dates may not be the 29th, 30th, or 31st of a month.
MONTH DAY YEAR
To process a periodic partial withdrawal arrangement, NYLIAC must receive this form at least five business days before the date the withdrawals
are to begin. The withdrawals will be effective on the date of the month you specify. If the day of the month specified is within five days of
NYLIACs receipt of this form, then the withdrawals will begin on the day specified in the following month.
3B: Tell us the frequency you would like to receive these scheduled withdrawals.
3C: 7HOOXVWKHGDWH\RXZRXOGOLNHIRUWKHƬUVWZLWKGUDZDOWREHZLWKGUDZQIURP\RXUSROLF\
STEP
4 Tell us the allocation alternatives from which the PPW or partial withdrawals should be made.
If no indLFDWLRQLVJLYHQSD\PHQWVZLOOEHWDNHQRQDSURSRUWLRQDOEDVLVEDVHGRQWKHDOORFDWLRQRIWKH$FFXPXODWLRQ9DOXHLQWKH$OORFDWLRQ
$OWHUQDWLYHVDWWKHWLPHRIWKHZLWKGUDZDO2WKHUZLVHSOHDVHVSHFLI\WKHGROODUDPRXQWV21/<3OHDVHXVHZKROHQXPEHUV)RUW
6XEVWDQWLDOO\(TXDO3HULRGLF3D\PHQWV6(33VIXQGVZLOO21/<EHGLVWULEXWHGRQDSURSRUWLRQDOEDVLV)RU5HTXLUHG0LQLPXP'LVWULEXWLRQDQG
3HUFHQWRI&XUUHQW$FFXPXODWLRQ9DOXH33:DUUDQJHPHQWVSOHDVHVSHFLI\WKHSHUFHQWDJHVLQZKROHQXPEHUV
)RU1HZ<RUN/LIH,QFRPH3OXVRU,QFRPH3OXV9DULDEOH$QQXLW\,,3ROLFLHVZLWKWKH*XDUDQWHHG)XWXUH,QFRPH%HQHnjW*),%3DUWLDO:LWKGUDZ-
DOVWDNHQEHIRUHWKH*),%3D\PHQWVDUHIXOO\IXQGHGZLOOEHWDNHQRQDSURSRUWLRQDOEDVLV3OHDVHQRWH*),%3D\PHQWVZLOOEHORZHUEDVHGRQ
the allocation of the Accumulation Value in the Allocation Alternatives at the time of the withdrawal.
)RU1HZ<RUN/LIH3UHPLHU3UHPLHU,,3UHPLHU3OXVDQG3UHPLHU3OXV,,9DULDEOH$QQXLW\SROLFLHVZLWKWKH*,35*,35,35,35,35
RU,35DOOSDUWLDOZLWKGUDZDOVZLOOEHWDNHQRQDSURSRUWLRQDOEDVLVEDVHGRQWKHDOORFDWLRQRIWKH$FFXPXODWLRQ9DOXHLQWKH$OORFDWLRQ
Alternatives at the time of the withdrawal.
5LVNFODVVLnjFDWLRQVDUHSURYLGHGLQWKHSDUHQWKHVHVDIWHUWKH,QYHVWPHQW'LYLVLRQ5LVNFODVVLnjFDWLRQVDUHGHWHUPLQHGRQWKHEDVLVRIWKH
0RUQLQJVWDU&DWHJRU\DVVLJQHGWRWKH,QYHVWPHQW'LYLVLRQE\0RUQLQJVWDU$QDO\WLFVDVRI'HFHPEHU0RUQLQJVWDULVDZLGHO\XVHG
LQGHSHQGHQWUHVHDUFKnjUPZKLFKUDQNVPXWXDOIXQGVDQGRWKHULQYHVWPHQWFRPSDQLHVE\RYHUDOOSHUIRUPDQFHLQYHVWPHQWREMHFWLYHVDQG
assets.
18484 0521 03
12
28
Print...
Next >
< Back
18484 (05/2021) 4
GUARANTEED
INTEREST ACCOUNT
NON
-
INVESTMENT GRADE
BOND
INVESTMENT
GRADE BOND
LARGE CAP EQUITY
STEP
4 Continued FUNDS
 Fixed Account - <HDU*XDUDQWHH

 Fixed Account - <HDU*XDUDQWHH1</LIH(VVHQWLDOV9DULDEOH$QQXLW\21/< 
131 6-Month DCA Advantage Plan
2

 12-Month DCA Advantage Plan
2

 18-Month DCA Advantage Plan
2

107
MainStay VP Bond - Service Class (Moderate) 
103 MainStay VP MacKay Government - Service Class (Moderate) 
162 MainStay VP PIMCO Real Return - Service Class
4
(Moderate) 
102 MainStay VP U.S. Government Money Market - Initial Class (Low) 
232 Fidelity
®
VIP Bond Index Portfolio - Service Class 2
(Moderate) 
 PIMCO VIT Income Portfolio - Advisor Classƺ0RGHUDWH 
 PIMCO VIT International Bond Portfolio (U.S. Dollar-Hedged) - Advisor Class
4
(Moderate) 
178 PIMCO VIT Low Duration Portfolio - Advisor Class
4
(Low) 
344 PIMCO VIT Total Return Portfolio - Advisor Class
4
(Moderate) 
144 MainStay VP Floating Rate - Service Class (Moderate) 
 MainStay VP MacKay Convertible - Service Class (Moderate) 
 MainStay VP MacKay High Yield Corporate Bond - Service Class (Moderate) 
 MainStay VP MacKay Strategic Bond - Service Class
4,8
(Moderate) 
 BlackRock High Yield V.I. Fund - Class III
4
(Moderate) 

Columbia Variable Portfolio- Emerging Markets Bond Fund - Class 2
4
(Moderate) 
 MainStay VP Epoch U.S. Equity Yield - Service Class (High) 
 MainStay VP MacKay S&P 500 Index - Service Class
(High) 
 MainStay VP T. Rowe Price Equity Income - Service ClassDŽ (High) 
 MainStay VP Wellington Growth - Service Class
5,10
(High) 
 MainStay VP Wellington U.S. Equity - Service Class
9
(High) 
 MainStay VP Winslow Large Cap Growth - Service Class (High) 
 American Funds IS
®
Growth Fund - Class 4ǂ ( High) 
188 American Funds IS Washington Mutual Investors Fund - Class 4
3,11
(High) 
 Clearbridge Variable Appreciation Portfolio - Class IIǂ (High) 
 Fidelity
®
VIP Contrafund
SM
- Service Class 2 (High) 
 Fidelity
®
VIP Equity-Income
SM
Portfolio - Service Class 2 (High) 
 Fidelity
®
VIP Growth Opportunities Portfolio - Service Class 2ǃ (High) 
 MFS
®
Investors Trust Series - Service Class (High) 
 MFS
®
Research Series - Service Class (High) 
145 MainStay VP Balanced - Service Class (Moderate) 
 MainStay VP Conservative Allocation - Service Class (Moderate) 
 MainStay VP Equity Allocation - Service Class
12
(High) 
150 MainStay VP Growth Allocation - Service Class
13
(High) 
 MainStay VP Income Builder - Service Class (Moderate) 
 MainStay VP Janus Henderson Balanced - Initial/Service Class
6
(Moderate) 
 MainStay VP Moderate Allocation - Service Class (Moderate) 
191 American Funds IS
®
Asset Allocation Fund - Class 4ǂ (Moderate) 
 BlackRock Global Allocation V.I. Fund - Class III Sharesǃ (Moderate) 
197 Fidelity
®
VIP FundsManager
®
60% Portfolio - Service Class
3
(Moderate) 
231 Franklin Templeton Aggressive Model Portfolio - Class II
3,14
(High) 
ASSET
ALLOCATION
Continued on the next page.
18484 0521 04
Print...
Next >
< Back
18484 (05/2021) 5
Continued on the next page.
STEP
4 Continued FUNDS
227 Franklin Templeton Conservative Model Portfolio - Class II
3,15
(Moderate) 
230 Franklin Templeton Moderately Aggressive Model Portfolio - Class II
3,16
(Moderate) 
228 Franklin Templeton Moderately Conservative Model Portfolio - Class II
3,17
(Moderate) 
229 Franklin Templeton Moderate Model Portfolio - Class II
3,18
(Moderate) 
192 MainStay VP IQ Hedge Multi-Strategy - Service Class
4
(Moderate)

 DWS Alternative Asset Allocation VIP - Class B
4
(Moderate) 
 MainStay VP Small Cap Growth – Initial
6
/Service
4
(Highest) 
 MainStay VP Wellington Mid Cap - Service Class
19
(High) 
 MainStay VP Wellington Small Cap - Service Class
20
(Highest) 
 Columbia Variable Portfolio - Small Cap Value Fund - Class 2 (Highest) 
 Delaware VIP Small Cap Value - Service Class
3
(Highest) 
 Fidelity
®
VIP Mid Cap - Service Class 2 (High) 
223 Invesco V.I. Main Street Small Cap Fund
®
- Series II Shares
3,21
(Highest) 
 Janus Henderson Enterprise Portfolio - Service Shares
3
(High) 
 MFS
®
Mid Cap Value Portfolio - Service Class

+LJK 
 Neuberger Berman AMT Mid-Cap Growth - Class S (High) 
 MainStay VP Candriam Emerging Markets Equity - Service Class
5,22
(Highest) 
 MainStay VP MacKay International Equity - Service Class (High) 
 American Funds IS
®
Global Small Cap Fund - Class 4
4
(High) 
 American Funds IS
®
New World Fund
®
- Class 4
4
(Highest) 
 Invesco V.I. International Growth Fund - Series II
4
(High) 
 Fidelity
®
VIP Emerging Markets Portfolio - Service Class 2ǂ (Highest) 
198 Fidelity
®
VIP International Index Portfolio - Service Class 2
3
(High) 
 Janus Henderson Global Research Portfolio - Service Shares (High) 
 MFS
®
International Intrinsic Value Portfolio - Service Class
3
(High) 
 MainStay VP CBRE Global Infrastructure - Service Class (High) 
 MainStay VP Fidelity Institutional AM
®
Utilities - Service Class (High) 
 MainStay VP Natural Resources - Initial Class
23
(Highest) 
 BNY Mellon IP Technology Growth Portfolio - Service Shares (Highest) 
 Columbia Variable Portfolio - Commodity Strategy Fund - Class 2
4,7
(Highest) 
199 Fidelity
®
VIP Health Care Portfolio - Service Class 2
3
(High ) 
 Morgan Stanley VIF U.S. Real Estate Portfolio - Class II
5
(High) 
ALTER-
NATIVES
SMALL/MID CAP
EQUITY
INTERNATIONAL/GLOBAL
EQUITY
SECTOR
1
The Fixed Account option is not available for New York Life Premier and Premier Plus Variable Annuity Policies sold in New York. It is also not available for all New York Life Income
Plus or Income Plus II Variable Annuity Policies.
2
Only the 6-Month DCA Advantage Plan Account is available for New York Life Premium Plus, Elite, Premium Plus Elite, Longevity Benefit, Premier, Premier II, Premier Plus,
Premier Plus II, Flexible Premium III and Complete Access II Variable Annuity policies. The 12-Month and 18-Month DCA Advantage plans only apply to New York Life Variable
Annuity and Essentials Variable Annuity policies. For the New York Life Select Variable Annuity policies, only the 6-Month and 12-Month DCA Advantage plans are available.
Only partial withdrawals may be requested from the DCA Advantage Plan Accounts. Periodic Partial Withdrawals from the DCA Advantage Plan Accounts are not permitted.
3
These Investment Divisions are not available for New York Life Select, Longevity, and Access Variable Annuity policies.
4
These Investment Divisions are not available for New York Life Select and Longevity Benefit Variable Annuity policies.
5
Premiums or transfers will not be accepted into this Investment Division on or after 11/13/2017 if you did not have Accumulation Value in this Investment Division prior to
11/13/2017. If you remove all of your Accumulation Value from this Investment Division on or after 11/13/2017, you will not be allowed to reinvest in this Investment Division.
6
Premiums or transfers will not be accepted into this Investment Division on or after 02/17/2012 if you did not have Accumulation Value in this Investment Division prior to
02/17/2012. If you remove all of your Accumulation Value from this Investment Division on or after 02/17/2012, you will not be allowed to reinvest in this Investment Division.
The MainStay VP Janus Henderson Balanced Service Class and MainStay VP Eagle Small Cap Growth Service Class impose a 12b-1 fee. Service class shares impose a 12b-1 fee.
Performance for these class shares is lower than for those that do not impose a 12b-1 fee.
If using percentages, then percentages in
funds chosen above must total 100% TOTAL $/%
ASSET
ALLOCATION
18484 0521 05
Print...
Next >
< Back
18484 (05/2021) 6
8
Continued on the next page.
7
Premiums or transfers will not be accepted into this Investment Division on or after 11/23/2020 if you did not have Accumulation Value in this Investment Division prior to
11/23/2020. If you remove all of your Accumulation Value from this Investment Division on or after 11/23/2020, you will not be allowed to reinvest in this Investment Division.
8
Formerly known as MainStay VP MacKay Unconstrained Bond - Service Class. Effective May 1, 2021.
9
Formerly known as MainStay VP MacKay Common Stock - Service Class. Effective May 1, 2021.
10
Formerly known as MainStay VP MacKay Growth - Service Class. Effective May 1, 2021.
11
Formerly known as American Funds IS
®
Blue Chip Income and Growth Fund - Class 4. Effective May 1, 2021.
12
Formerly known as MainStay VP Growth Allocation -Service Class. Effective May 1, 2021.
13
Formerly known as MainStay VP Moderate Growth Allocation - Service Class. Effective May 1, 2021.
14
Formerly known as Legg Mason/QS Aggressive Model Portfolio - Class II. Effective May 1, 2021.
15
Formerly known as Legg Mason/QS Conservative Model Portfolio - Class II. Effective May 1, 2021.
16
Formerly known as Legg Mason/QS Moderately Aggressive Model Portfolio - Class II. Effective May 1, 2021.
17
Formerly known as Legg Mason/QS Moderately Conservative Model Portfolio - Class II. Effective May 1, 2021.
18
Formerly known as Legg Mason/QS Moderate Model Portfolio - Class II. Effective May 1, 2021.
19
Formerly known as MainStay VP MacKay Mid Cap Core - Initial Class. Effective May 1, 2021.
20
Formerly known as MainStay VP MacKay Small Cap Core - Service Class. Effective May 1, 2021.
21
Formerly known as Invesco Oppenheimer V.I. Main Street Small Cap Fund
®
- Series II Shares. Effective May 1, 2021.
22
Formerly known as MainStay VP Emerging Markets Equity - Initial Class. Effective May 1, 2021.
23
Formerly known as MainStay VP Mellon Natural Resources - Initial Class. Effective May 1, 2021.
STEP
4 Continued FUNDS
Send me a check to the address below.
Send proceeds directly to my bank account listed below via Electronic Funds Transfer (EFT). If we are unable to send your payment(s) via EFT to
the bank account provided, we will send a check to the address of record or the address provided in Step 1.
If the day you have chosen for your Periodic Partial Withdrawal payments falls on any day which is not a business day (e.g. 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 business day the payment is made.
Note: Your Financial Institution must be a member of the Automated Clearing House (ACH). Please check with your Financial Institution.
The account holder of the bank account must be an Owner of the Annuity. If the Financial Institution is a member of the ACH, your payments will be
processed via Electronic Funds Transfer (EFT). By electing EFT, you agree that all payments so made shall discharge New York Life to the extent of
the payments. In addition, you understand that because of New York Life’s annuity payment processing requirements and, if applicable, the Financial
Institution’s processing requirements, your EFT payment receipt date (the day the payment is available in your account) may be later than the start
date you elect, or the date the withdrawal is requested. You further agree that any EFT payments made after your death shall not be held for the
EHQHILWRI\RXUHVWDWHEXWVKDOOEHUHSDLGWR1HZ<RUN/LIHXSRQUHTXHVW<RXDXWKRUL]HDQGGLUHFWWKH)LQDQFLDO,QVWLWXWLRQWRUHIXQGWR1HZ<RUN/LIH
an amount equal to any payments made after your death, and if such payments shall have been credited to your account, or to the account of your
estate, to change such account accordingly.
Address
STREET APT. CITY S TAT E ZIP
Routing Bank name
number
Account
Name of account holder
number
Checking
Savings
STEP
5 Tell us how you would like to receive your PPW/partial withdrawal proceeds (select only one).
Are you a citizen of the United States?
Yes
No
Please select one of the following withholding options applied for this payment.
NO Federal or State taxes withheld
ONLY Federal taxes withheld % (Not available in certain states)
BOTH Federal % and State %
ONLY State taxes withheld %
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 you elect to have
IHGHUDOWD[HVZLWKKHOGVWDWHZLWKKROGLQJPD\DSSO\GHSHQGLQJRQ\RXUVWDWHRIUHVLGHQFH,I\RXUWD[SD\HULGHQWLƬFDWLRQQXPEHU6RFLDO6HFXULW\QXPEHURU
HPSOR\HULGHQWLƬFDWLRQQXPEHULVQRWSURYLGHGLQ6WHSRULIDZLWKKROGLQJHOHFWLRQLVQRWVHOHFWHGZHDUHUHTXLUHGE\IHGHUDOODZWRZLWKKROGRIDQ\
WD[DEOHJDLQWKDWPD\UHVXOWIURPWKLVWUDQVDFWLRQ3OHDVHƬOORXWIRUHDFKSROLF\RZQHU
STEP
6 Tell us about your tax withholding election. This will be applied to this withdrawal and any future withdrawals under this policy.
18484 0521 06
WY
Print...
Next >
< Back
18484 (05/2021) 7
1RWDUL]HGFRQƬUPDWLRQ0HGDOOLRQVLJQDWXUHJXDUDQWHHIRUDPRXQWVJUHDWHUWKDQ5(48,5('
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 purpose therein contained.
Notary stamp
Notary Public Print name Date commission Expires
Under penalties of perjury, I (as owner named) certify:
1. My Social Security number or Tax ID number shown on this form is my correct taxpayer
LGHQWFDWLRQQXPEHU,DPQRWVXEMHFWWREDFNXSZLWKKROGLQJEHFDXVHD,DPH[HPSWIURPEDFNXSZLWKKROGLQJE,KDYHQRWEHHQQRWLƬHG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QRWLƬHGPHWKDW,DPQR
ORQJHUVXEMHFWWREDFNXSZLWKKROGLQJ,DPD86SHUVRQLQFOXGHVD86UHVLGHQWDOLHQDQG7KH)$7&$FRGHHQWHUHGRQWKLVIRUPLIDQ\LQGLFDWLQJ
WKDW,DPH[HPSWIURP)$7&$UHSRUWLQJLVFRUUHFW3OHDVHQRWHLIEHLQJVXEPLWWHGIRUD86DFFRXQWWKLVODVWFHUWLƬFDWLRQGRHVQRWDSSO\
&KHFNWKLVER[LIWKH,56KDVQRWHG\RXWKDW\RXDUHVXEMHFWWREDFNXSZLWKKROGLQJ
,I\RXDUHD86HQWLW\\RXPXVWVXEPLWDFRPSOHWHG,56)RUP:,I\RXDUHQRWD86FLWL]HQ86UHVLGHQWDOLHQRURWKHU86SHUVRQ\RXPXVW
VXEPLWWKHDSSOLFDEOH)RUP:ZLWKWKLVIRUPWRFHUWLI\\RXUIRUHLJQVWDWXVDQGLIDSSOLFDEOHFODLPWUHDW\EHQHƬWV
If you are not a U.S. person, your
signature below only applies to the provisions of this document other than the provisions contained in this Owner Tax Certification section.
Enter your Social Security number if you are an individual.
7KH,QWHUQDO5HYHQXH6HUYLFHGRHVQRWUHTXLUH\RXUFRQVHQWWRDQ\SURYLVLRQRIWKLVGRFXPHQWRWKHUWKDQWKHFHUWLƬFDWLRQVUHTXLUHGWRDYRLGEDFNXSZLWKKROGLQJ
STEP 8 Done! Send us your completed form.
Continued on the next page.
Title of Officer Name
Policy owner/Officer/Trustee signature (if applicable) (Print) Date
Title of Officer Name
Policy owner (required if joint owner) Officer/Trustee signature (if applicable) (Print) Date
Name
Assignee signature (if applicable) (Print) Date
Name
Assignee signature (if applicable) (Print) Date
X
X
X
X
Mail: New York Life, Variable Products Service Center, Madison Square Station, PO Box 922, New York, NY 10159
Questions? Call us at 1-800-CALL-NYL
ONLINE: Save time and postage by uploading this form at newyorklife.com/register. Log in or register to upload in minutes.
<RXUVLJQDWXUHVFRQƬUPWKDW\RXXQGHUVWDQGDQGDJUHHWKDW
You have read all the information on this form and that the information you have provided is correct.
:KHUHWKHRZQHULVDFRUSRUDWLRQRUWUXVWSOHDVHSURYLGHVLJQDWXUHVRIWZRFRUSRUDWHRƯFHUVRUDOOWUXVWHHVDVZHOODVWKHLUUHVSHFWLYHWLWOHV
Where the owner is a partnership, the form must be signed by two partners other than the annuitant. In the case of a limited partnership, only the
signature of general partner is required.
Where the policy is assigned, the assignee’s signature is required in addition to the policy owner’s signature. If the assignee is a bank or corporation,
WZRRƯFHUVPXVWVLJQ,ISROLF\LVMRLQWO\RZQHGDQGKDVDQRWKHUGHVLJQHHVZKRLVDXWKRUL]HGWRUHTXHVWWUDQVDFWLRQVRQWKHSROLF\WKHVLJQDWXUHVRI
DOOMRLQWRZQHUVDQGGHVLJQHHVDUHUHTXLUHG$OOVLJQDWRULHVPXVWSURYLGHWKHLU7D[,GHQWLƬFDWLRQ1XPEHU
Where the policy owner is a person acting as a guardian, conservator or in a similar capacity, evidence of appointment must accompany the form.
3DUWLDOZLWKGUDZDOUHTXHVWVIRUDPRXQWVJUHDWHUWKDQPXVWEHUHFHLYHGLQDIRUPDFFHSWDEOHE\XVDQGLQFOXGHDQRWDUL]HGFRUPDWLRQRIWKH
owner’s signature or a medallion signature guarantee.
Owner distributions that are taxable will be reported to the IRS on Form 1099R.
It is the participant’s responsibility to meet the IRS requirements that qualify for this distribution.
7KHHƪHFWLYHGDWHRIWKLVUHTXHVWZLOOEHWKHGDWHLWLVUHFHLYHGLQWKH9DULDEOH3URGXFWV6HUYLFH&HQWHURI1HZ<RUN/LIH,QVXUDQFHDQG$QQXLW\
Corporation (NYLIAC), completed with all required information for processing.
Once the withdrawal is processed, NYLIAC is not obligated to accept any return of the monies distributed.
Distributions that are paying a premium a premium on another New York Life or Long Term Care policy number(s) will be sent directly to the
administrator of the policy number(s)
STEP 7 Read and sign.
2ZQHU7D[&HUWLƬFDWLRQ
18484 0521 07
Print...
Next >
< Back
18484 (05/2021) 8
Important Federal Income Tax Withholding Information
This information is required to carry out the Internal Revenue laws of the United States and to provide you with some basic information about
withholding of Federal income tax from your payment under the policy specified in the Income Tax Withholding Election section.
A withdrawal may result in a taxable gain reportable to the IRS. Generally, Federal withholding applies to taxable payments made from pension,
profit-sharing, stock bonus, annuity and other employer deferred compensation plans, individual retirement arrangements (IRA), and commercial
annuities (which include individual annuity, life insurance and endowment policies). If you make a withdrawal before you reach age 59½, you also
may be subject to a 10% penalty tax on any taxable gain. This would be in addition to any income tax you may be subject to on that taxable gain. If
you take a distribution from a SIMPLE IRA during the 2-year period beginning on the date you first participated in the SIMPLE IRA plan, the penalty
tax described above is increased from 10% to 25%. Please consult a professional tax advisor for more information on this tax penalty 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 Income Tax Withholding Election section. Non-persons such as corporations, companies,
WUXVWVHWFRU86FLWL]HQVOLYLQJRXWVLGHWKH8QLWHG6WDWHVFDQQRWHOHFWRXWRIZLWKKROGLQJ*HQHUDOO\\RXUHOHFWLRQDVWRZKHWKHUWD[HVDUHRU
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 the Income Tax Withholding Election section.
Even if you elect not to have Federal income tax withheld, you are liable for payment of such tax on the taxable portion of your payment. There are
penalties under the estimated tax payment rules if enough tax has not been paid through either estimated tax payments or withholding. As noted
above, there is also an additional 10% tax penalty imposed by the IRS that applies to certain policy gains on premiums paid after December 31, 1982
for withdrawals before you reach age 59½.
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 tax is
not required to be withheld.
We will not withhold Federal income tax if the payment is being made to the Trustees of a qualified pension or profit sharing plan.
One Indirect Rollover Per Year Rule (Applies to Traditional, Roth, SEP and SIMPLE IRAs)
Beginning January 1, 2015, you can make only one rollover from an IRA to another (or the same) IRA in any 12-month period, regardless of the
number or types of IRAs you own (see IRS Announcement 2014-32). Generally, a rollover is a tax-free withdrawal of all or part of the assets from
one IRA that you contribute (roll over) within 60 days to another (or the same) IRA. You can, however, continue to make an unlimited number of
trustee-to-trustee transfers (transfers directly between IRAs). You can also make an unlimited number of rollovers from traditional IRAs to Roth
IRAs (“conversions”). If you are considering requesting a distribution from your IRA for rollover to another IRA, you should strongly consider a
trustee-to-trustee transfer instead. Please consult your tax advisor prior to effecting a rollover.
Please consult your tax advisor for complete details of the rules stated above.
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.
Important State Income Tax Withholding Information
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.
For residents of Arizona, Indiana, Louisiana, Maryland, Missouri, Montana, New Jersey, New Mexico, New York, Utah, and Wisconsin: 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.
For residents of Arizona: State income tax withholding is voluntary and only applies to periodic payments. Withholding election requests
PXVWEHDFFRPSDQLHGE\$UL]RQD)RUP$3
18484 0521 08
Print...
< Back