New York Life Annuities

Death Benefit Form for Annuity Proceeds

ANN18743-717

Annuities are issued by New York Life Insurance and Annuity Corporation (NYLIAC) (A Delaware Corporation)
Variable annuities are distributed by: NYLIFE Distributors LLC, Member FINRA/SIPC
NYLIAC and NYLIFE Distributors LLC are wholly owned subsidiaries of New York Life Insurance Company
51 Madison Ave, New York, NY 10010

ANNUITIES Not FDIC/NCUA Insured Not a Deposit May Lose Value Have No Bank Guarantee Not Insured by Any Government Agency
 NYL Annuity Service Center
PO Box 9859
Providence, RI 02940

Receiving the benefits intended for you.

Dear Beneficiary,

Please accept our condolences on your loss during this difficult time.

We are providing the enclosed Death Benefit Proceeds kit to make it as easy as possible for you to receive
the benefits intended for you by our policyowner. Please return a completed Death Benefit Form, an original,
certified copy of the death certificate, and any additional required documents specified herein, so that we can
process your benefit as promptly as possible.

For assistance in completing the form or understanding what information is required, you may contact a client
services representative at 1-877-926-7147, Monday through Friday from 8:30 A.M. to 5:30 P.M. ET.

We appreciate the trust placed in us by millions of policyowners and their beneficiaries for over 170 years and
are proud to continue that tradition in service to you.

On behalf of New York Life,

Simon Walsh
Vice President

1609706
Important Information

Death Certificates:
A)One original or certified copy with a raised seal is required for processing. The death certificate will not be
returned.
B)If the cause of death on the death certificate is Pending or Under Investigation, we will require an original
updated death certificate showing cause of death to process the claim.
Foreign Address - U.S. Citizens living abroad must provide a W-9 and may be subject to 10%FederalTaxwithholding.
Non U.S. Citizens, in order to claim benefits under a U.S. Tax Treaty (if available), a W-8BEN (W-8BEN-Efor Entities) is
required with your tax identification number issued to you by your country of residence. If not, mandatory 30% tax
will be withheld.
Minors - if the amount is over the state of residence minimum, court appointed Guardianship paperwork with
proof of identity is required. If the amount is under the minimum, the minors birth certificate, proof of residence
and the parent or care givers proof of identity (such as a drivers license) is required. Minors may also wait until they
are of legal age to make the claim.
Trusts - trust paperwork showing the title, settlers/grantors info, successor trustee pages and signature pages are
required along with any amendments to the trust. All trustees are required to sign.
Estates - must provide court appointed Estate paperwork with visible stamp or seal.
Corporations - Corporate Resolution showing authorized signer is required.
Attorneys or Third Parties - must have written authorization from the beneficiaries to release information on the
policy.
Powers of Attorneys - must provide a copy of the Power of Attorney paperwork. Most states require a notary seal.
Name Changes - must provide legal proof of the name change, i.e. marriage license, divorce decree or court
paperwork.
IRA (Individual Retirement Accounts) - inherited IRAs cannot be rolled over and require transfer paperwork as they
do not follow the same IRS rules.

Remember to Review and Include

One original or certified copy with raised seal of the death certificate
Completed claim form for each beneficiary, signed and dated
Social Security Number or Tax Identification Number for entities (trusts, estates, corporations, etc)
Completed W9s are required for entities (trusts, estates, corporations, etc)
Any state requirements or additional requirements as specified herein
STOP
State tax withholding forms may be required. Please see the Income Tax Certification and Withholding section
on page 5.
 New York Life Annuities Death Benefit Form

THE ORIGINAL DEATH CERTIFICATE IS REQUIRED FOR PROCESSING AND WILL NOT BE RETURNED.
1. Policy Numbers: Please list all policy numbers for your claim. If you wish to elect a different option for each policy, please fill out a
separate claim form for each policy.

2. D
 ecedent Information: Please tell us about the deceased.
Name of Deceased (First, Middle, Last) Nickname or Maiden Name

Deceaseds Date of Birth Deceaseds Place of Birth (State, Country)

Deceaseds Date of Death State of Residence at Time of Death Deceaseds Social Security Number

Cause of Death Natural Homicide Pending/Unknown

Accident Other_______________________________________________________________

3. B
 eneficiary Information: Please tell us about yourself.
Name (First, Middle, Last) or Entity Name Sex: Nickname or Maiden Name
Male Female
Date of Birth Social Security/ Tax I.D Number Daytime Phone Number Email Address

Residential Address City State Zip Code

Mailing Address (if different than above) City State Zip Code

Check one:
I am a US Citizen or Resident Alien I am a Non-Resident Alien or a Foreign Entity*
Check one:
Beneficiarys Relationship to the Deceased
Spouse Child Grandchild Parent Other: _____________________________________
Check one:
In what capacity are you making this claim?
Individual Beneficiary: A person claiming on their own behalf. Please note that if you request benefits to be paid to a funeral home,
a copy of the assignment and itemized statement is required.
Minors: Payments on behalf of a minor must be made to an authorized representative of the minor, such as (i) a Custodian under
the Uniform Transfers/Gifts to Minors Act, or (ii) a court designated Guardian of the Person and Estate or Estate of the minor.
Corporation: A copy of the corporate resolution is required. A completed W-9 form for the Corporation is required.
Estate: A copy of the certified appointment papers is required. A completed W-9 form for the Estate is required.
Trust/Trustee: Copy of Trust or amendments are required. A completed W-9 form for the Trust is required.
Collateral Assignee: A copy of the assignees statement of interest must be provided. A completed W-9 form for the Assignee is
required.
* If you are a non U.S. citizen or resident, a completed W-8BEN form is required. For a foreign entity, please use W-8BEN-E. If you
are a resident Alien, please send a copy of your green card. For U.S. citizens living abroad, W-9 form is required. Please refer to
the Internal Revenue Service website at www.irs.gov for the appropriate tax form.

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4. Choose Your Claim Option
Please choose a claim option and complete the additional sections noted under that option. Certain options may not be available to
you depending on the type of annuity, your relationship to the decedent, when you make your claim or if the beneficiary is a non living
entity.

A. Lump Sum Payment - Some restrictions may apply. Please distribute the death benefit to me in one lump sum payment.
(This is the only option available for Estate and Testamentary Trust beneficiaries).

B. Spousal Continuance - not available on Tax Sheltered Annuities - I am the surviving spouse and sole primary beneficiary
of the policy(ies). I wish to continue the policy(ies) and defer taxes. I understand that by electing this option no death benefit
will be paid and the policy will continue in my name in accordance with the terms of the original policy(ies) referenced above.
Must complete section 7 or the new beneficiary will become the Estate.

By checking the following option(s), I wish to continue the scheduled activity(ies) on the policy(ies) that I am continuing. Must
complete sections 5 and 6. I understand that if there is an existing scheduled activity and it is not marked, it will automatically
be discontinued.

Periodic Partial Withdrawal Arrangement/Required Minimum Distribution

Automatic Asset Reallocation (Variable Accounts Only)
Dollar Cost Averaging (Variable Accounts Only)
Interest Sweep (Variable Accounts Only)

C. Continuance of Payments - I understand that the deceased was receiving income payments. I wish to continue the
scheduled payments on the policy. Must complete sections 5 and 6.

D. Settlement Account Options are only available within a year of the Decedents Date of Death. Not available
on immediate income/annuitizied policies. Minimum of $5,000. Amounts elected below must equal one year of payments.
For detailed information regarding the settlement options, please refer to the Settlement Account Options section on
page 5. Entities must provide trustee/annuitant information in section 8 including Social Security Number, date of birth,
address, and telephone number. Must complete sections 5 and 6.
Check one:
Income for an Elected Period
Choose the number of years that you want to receive payments (2 to 30 Years): _____________

Income of an Elected Amount

Choose your minimum periodic payment: $ _____________

Life Income: Guaranteed Period*

Choose your guaranteed period (5, 10, 15, or 20 years): _____________

Life Income: Guaranteed Total Amount*

* Not Available for Non-Living Entities (Trusts, Corporations, etc.)

Payment Start Date: Must be within a year of the decedents Date of Death. If a date is not selected
/ / or if the date has past, we will default to one month from the issue date of
(Month) (Day) (Year) your settlement account. You may not select the 29th, 30th or 31st of any
month. If any of these dates are selected, we will default to the 28th.

Payment Frequency: If not checked, payments will be made Monthly.

Monthly Quarterly Semi-Annually Annually

E. Internal Exchanges - Transfer of proceeds to a New York Life policy. Must be accompanied by a New York Life annuity
application. (If you wish to open a new annuity with New York Life, please contact a licensed broker oragent).

F. Inherited IRA or Beneficiary 1035 Exchange - Transfer of proceeds to another carrier. Must provide Transfer or 1035
Exchange paperwork signed by the receiving company. Must be within one year of the date of death due to RMDs (if applicable)
and distributions.

G. Other - Complete section 8 or provide a letter of instruction.

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5. Income Tax Certification Section
If a withholding election is not selected, we are required by Federal law to withhold 10% of any taxable gain that may result from
this transaction. (Some Products/States may vary). Mandatory 20% Federal Income tax must be withheld for all tax-sheltered
annuitypayments - does not apply to nonspouse beneficiaries.
If your state requires withholding, we will withhold the states minimum amount if you do not make an election, or if you select an
amount that is less than the minimum. See the important State Tax Withholding information on page 5 for more information.
Please check your State Tax Authorities Website for information on state specific forms.
I DO NOT want to have Federal Taxes withheld (20% Federal Income Tax for all Tax Sheltered Annuity Payments - does not apply to
nonspouse beneficiaries).
I DO want to have % Federal Income Tax Withheld. (Use whole percentages).
I DO NOT want to have State Income Tax Withheld. (MI residents must provide a MI W-4P to opt out of State Tax).
I DO want to have % State Income Tax Withheld.

6. Where To Send Your Payment(s):

If you do not choose a payment method, a check will be mailed to the mailing address specified in Section 3.

Payment Method:
Beneficiary Mailing Address in section 3 Brokerage Account Other, please explain: ______________________
Checking Account (attach a voided check) Savings Account

Name of Financial Institution:

Address:
Address:
Routing Number:
Account Number:
Account Holders Name(s):

If payments are to be deposited into a brokerage account, please complete For Further Credit To below in addition to the above
information.
For Further Credit To:
Trusts/Estates: Voided Check must be in the Trust/Estate Name
New York Life cannot direct deposit funds into a third party account or out of the U.S.

7. Beneficiary Designation: Required only for Spousal Continuances (option B) and Settlement Accounts (option D) in section 4.
Percentages must total 100% or may default to the Estate. Use section 8 for additional Beneficiaries.
Primary Social Security or Tax ID Number Relationship to Owner Percentage
Full Name (First, Middle Initial, Last)
Telephone Date of Birth
(mm/dd/yyyy) %
Address: Street
City StateZip Code

Primary or Contingent Social Security or Tax ID Number Relationship to Owner Percentage

Full Name (First, Middle Initial, Last)
Telephone Date of Birth
(mm/dd/yyyy) %
Address: Street
City StateZip Code

Primary or Contingent Social Security or Tax ID Number Relationship to Owner Percentage

Full Name (First, Middle Initial, Last)
Telephone Date of Birth
(mm/dd/yyyy) %
Address: Street
City StateZip Code

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8. Additional Information: If you need additional space, please attach a signed and dated letter of instruction to your Claim.

9. Your Signature:
Your signature confirms that all information on this form is correct.

Any person who knowingly and with intent to defraud any insurance company or other person, files an application for insurance or
statement of claim 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 to a civil penalty not to exceed
five thousand dollars and the stated value of the claim for each such violation. Please refer to the enclosed page entitled STATE
VARIATIONS OF FRAUD WARNINGS for specific notices required in certain jurisdictions.

The Internal Revenue Service does not require consent to any provision of this document other than the certifications required to
avoid backup withholding.

Under penalties of perjury, I certify that: (1) My Social Security Number or Tax ID Number shown on this 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 have not been notified by the IRS that I am subject to backup withholding as a result of a failure to report
all interest or dividend income; or (c) the IRS has notified me that I am no longer subject to backup withholding, (3) I am a U.S.
person (including a U.S. resident alien), and (4) I am exempt from Foreign Account Tax Compliance Act (FATCA) reporting.

NOTE: Check this box if the IRS has notified you that you are subject to backup withholding.
If I am not a U.S. citizen, U.S. resident alien or other U.S. person, I am submitting the applicable IRS Form W-8 with this form
to certify my foreign status and, if applicable, claim treaty benefits.

Signature Date signed

Print Name

Signature Date signed

Print Name

Return this form, along with an original or certified copy of the death certificate, and other applicable claim requirements to:

Regular Address: Overnight Address:

New York Life Annuity Service Center New York Life Annuity Service Center
PO Box 9859 C/O BNY Mellon
Providence, RI 02940 4400 Computer Drive
Westborough, MA 01581

Service Center Phone Number: 1-877-926-7147 Fax Number: 1-508-599-6109

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Your Settlement Account Options:
If you request a Settlement Account, payments must begin within a year of the decedents Date of Death. If you are filing your claim
more than a year after the Date of Death, your remaining options will be a Lump Sum Distribution or Spousal Continuance (if applicable).
Income for an Elected Period For Individuals and Non-Living Entities:
You may choose a certain period of years in which to receive payments (between 2-30 years; non-living entities are limited to a
maximum of five years). The elected period cannot exceed your life expectancy. At the end of the elected period, 100% of the death
benefit will have been distributed.
Interest accrues on the remaining balance in the account. The interest rate is declared annually by New York Life, in January of each
year, and may change the amount of your periodic payment.
Other than the periodic payments, you cannot request a partial withdrawal from this account, but you may choose to withdraw the
entire amount remaining at any time.
If you should die before the elected period ends, your beneficiary(ies) will receive a lump sum distribution of the remaining value.
Income of an Elected Amount For Individuals and Non-Living Entities:
You may choose a minimum periodic amount to be paid (i.e. $500 per month) until all of the death benefit proceeds have been
distributed. Excess Interest is added to this minimum periodic payment, so that your total periodic payment will be equal to the
minimum periodic payment plus an amount of excess interest.
The amount of time it takes to distribute the entire account cannot exceed your life expectancy. Non-living entities must choose a
minimum periodic payment wherein all proceeds are distributed within five years.
Interest accrues on the remaining balance in the account. The interest rate is declared annually by New York Life, in January of each
year, and may change the amount of excess interest added to your minimum periodic payment.
Other than the periodic payments, you cannot request a partial withdrawal from this account, but you may choose to withdraw the
entire amount remaining at any time.
If you should die before the elected period ends, your beneficiary(ies) will receive a lump sum distribution of the remaining value.
Life Income: Guaranteed Period For Individuals Only:
You will receive equal fixed payments for the rest of your life, and choose a guaranteed period of 5, 10, 15, or 20 years. The elected
guaranteed period cannot exceed your life expectancy.
If you should die before the end of the guaranteed period, payments will continue to your beneficiary for the remainder of the
guaranteed period. If you die after the guaranteed period has expired, no payments will be made to your beneficiary.
Other than the periodic payments, you will not be able to withdraw any amount from the account, whether a partial or full withdrawal.
Life Income: Guaranteed Total Amount For Individuals Only:
You may choose to receive equal fixed payments for the rest of your life.
If you should die before the total value of the payments made to you equals the death benefit proceeds placed in the settlement,
your beneficiary(ies) will continue to receive payments until such time that the combined total of all payments made to you and your
beneficiary(ies) equals the amount placed in the settlement.
Other than the periodic payments, you will not be able to withdraw any amount from the account, whether a partial or full withdrawal.

Income Tax Certification and Withholding

Important Federal Income Tax Withholding Information: Any withdrawal may result in a taxable distribution, which we will report to the
IRS. In general, if the withdrawal is from a Qualified Annuity, the whole amount of the withdrawal is generally reported as taxable. For a
Non-Qualified Annuity, typically only a portion of the payment is taxable. For lump sum payments, we will withhold federal income tax
at the minimum rate of 10% of the taxable portion of a withdrawal, unless you elect not to have federal income taxes withheld. You can
make this election by filling out section 5 of your claim form. You must provide us with your Social Security Number to make this election.
If you have chosen a Settlement Account with periodic payments, federal income tax must be withheld in the same manner as
withholding for wages, unless you elect not to have withholding apply to the taxable portion of your payment. You can make this
election or change a previous election at anytime by sending us an IRS Form W-4P. The form can be mailed to us at NYL Annuity
Service Center, PO Box 9859, Providence, RI 02940. Generally, your election as to whether taxes are or are not to be withheld will
apply to any other payment from the same policy. If you do not elect out of withholding, we will withhold as if you were married
claiming three withholding allowances, unless you complete and send us an IRS Form W-4P indicating otherwise.
If you are a U.S. Citizen or resident alien receiving payments delivered outside the United States or its possessions, you cannot elect
out of withholding. Other recipients receiving payments outside of the United States or its possessions, such as non-resident aliens,
are generally subject to 30% withholding but may be exempt from or subject to withholding at a lower rate if an applicable treaty so
provides by completing IRS Form W-8BEN and providing an Individual Taxpayer Identification Number.
U.S. residents will receive a Form 1099-R and 1099-INT for any taxable amounts received and non-resident aliens will receive Form
1042-S. 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.
State Income Tax Withholding: In addition to the Federal income tax withholding requirements, some states require withholding on
the taxable portion of payments. If you reside in one of these states, we will withhold state income taxes as required by your state.
Although state regulations differ, those states requiring withholding generally allow you to elect of out withholding. If you are unsure
as to whether your state requires withholding, please consult your tax advisor.

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 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 fines and
confinement in state prison.
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 include imprisonment, fines,
denial of insurance, and civil
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 a false or fraudulent
claim for payment of a loss or
benefit or knowingly presents
false information in an application
for insurance is guilty of a crime
and may be subject to fines and
confinement in prison.
Florida
Any person who knowingly and
with intent to injure, defraud,
or deceive any insurer files
a statement of 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 or benefit or who
knowingly or willfully presents
false information in an application
for insurance is guilty of a crime
and may be subject to fines and
confinement in prison.
New Jersey
Any person who knowingly
files a statement of claim
containing any false or misleading
information is subject to criminal
and civil penalties.
Oregon
Any person who knowingly
and with intent to defraud any
insurance company or other
person files an application for
insurance or statement of
claim 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
misinformation 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
benefits.
Pennsylvania
Any person who knowingly and with
intent to defraud any insurance
company or other person files an
application for insurance or statement
of claim 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 of a
loss or any other benefit, or presents
more than one claim for the same
damage or loss, shall incur a felony and,
upon conviction, shall be sanctioned
for each violation with the penalty of
a fine of not less than five thousand
dollars ($5,000) and not more than
ten thousand dollars ($10,000), or a
fixed term of imprisonment for three
(3) years, or both penalties. Should
aggravating circumstances be present,
the penalty thus established may be
increased to a maximum of five (5)
years, if extenuating circumstances
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 files an
application for insurance or statement
of claim 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 imprisonment,
fines, or a denial of insurance benefits
if a person provides false information.