Withdrawal Request

lnstructions
thr thlr lorn tq roquct elther a full rurrendc or r prrthl dthdnwal of your rnnulty contrrct/certlllcNts for contr&ti not beucd ln
Ilrw Yor{c Ure foffi lt0tls for oorffrc$ lnuod ln l{rw York.
liiPotTAilt We reommend that you rwlanr your produa prospecnrs and/u contact/cedflete wltr your a&lsor fur furdrer detalls regardlng ilre impac of wlthdrawals.
r Be a&leed $at uking wi$drawals from somr of our produr:ts mry adverc€ly affect $e underlylng guarantees,
r W$drawals from a variable annuity produc wl$ a guaranteed mlnlmum wlfidrawal benefit may impac that benefrt
o For Annultyl{ots producG, any uns$eduled withdrawrl mry reduce or eliminate $e Ufetime lncome Amount"
o For oilter varlable
annulty producs, $s Ufutlme lnome Amount may be reset or ellmlnated for ary wlthdranrals taken prior to the Lifetime lnome Date or
for a wlfidrawal teken alFr $e Lifutime lncome Date {ut exceds fre Lifaime lnome Amount,
r Amounts witMrawn o,s your allotted penalty ftee amount (lncludlng interec) may be subjec to wiftdranral dnrges.
r Amoun8 wlthdrawn from your contact cannot be relnstatd.
Sonr rddltlonrl ruqulremcttr mry epply to ccrtdn udthdrdyd$
r When requesting a dhea rollover or tan*r, a slgned 'Lttt€t of Acceptance' is requircd. this fom cannot be used for t 035 Exdranges.
. Slgnature Guarantees ate required when a slgnd appllcatlon or confirmatlon of appllcatlon is not on file, a wl$drawal dre* is hing mailed to an ahernate
addtes$ $ere has been an address dange wiftin the last 30 doys, or when a withdrawal in $e amoufi ol f250,000 or more b requ-ested, Arry ol tese request
requirlng a Slgnature Guarantee must be orlglnal; facsimlles wlll not be acreptd. Signature Guarantees are used to help protec aginst fraud bnd may be obtained
at most banks, linancial instlMlons, or credlt unions.
Please rEfar to sectlon 7 for addhlonal information regprdlng sections 2, 3, 4 & 5.
lill0itrAilf, Please note $at ff you are reeMng a sedes of sub*antlal| equal paymeflb in order to avold dre I M early wltMnual penalty under Section 72 of tre
lmemal Revenue Code ary unsdduled wlthdrawal from your onfirct will be onsiderd a modificatkrn, and resh in dre lmposition of dre 1fl/o penalry b all pradow
and poesibly suhequent wlhdnwals, Plme onsrh your tD(.dvlsor fil ddilional infomration,

lnformation About You

1 ,o*oo, FL OOZ e oZZ wrne/sphone*: b -85 - 57o
owne/sNamer GtPgoP K. KtuoNzo Social Seority #/IlN: t9-
Co-0wna/s Name: Social Security #/tlN:
Agent's Name (if applicable): Agenfs Phone #:

Withdrawal lnstructions (Please select only ONE of ttre folloMng options)

2
Optlon 2. E Spcclfc amount f
E Pronate withdtawal lrom all varlable funds {defaul0
-
F Fund Speclflc Request lndicate belou, tom whi$ portfolios you would llke your wi$drarval redeemed;
t- or-% lrom dre portfolio i- or Yo from dre portfolio
t- or from the portfollo $- or fiom dre portfollo
$_ --Yo
T0tal:
n Net (Deftuh): All appllcabl€ ta( vd$holdlry and runmder drarg* (f ffiese$ will be d€duchd
-%fdn the remainlng wlue in your ccntact

..............F..9ni11.:p!lef!:.1?rvlt!'.?]9!rslr9.::r.t9:r:F.rys.{f.?rs.9.YT.F.gSrI*.1T.$.::.yr.$.:1r.11.... ........
O$lon l. Frcs Amomt - This op$on refen to $e Frus Amount as defined by ilre produa prospectus and/or contracUcertificate. This amount may differ
from the optionalwithdrawal benefit amount (lnformatlon regarding $e calcuhtion ol fies€ benelir on be found in your prospectus, onllne at
lwwttjhannulties.com, on your quarteily sbtaneni or by contactlng our Seruice Center).
E Calculau and dlstrlbute my Free Amount
E Calculab and distibub my maxlmum amount available under tlry orrent living benefit rider wl$out reset
El Caladate and dlstribute my Maxlmum Amount wisrout Sunender Penalty.*
*Usually
indudc fte tee amount plus all payment uskle $eir $ren&r dledule. Plem re{er to pur omact/certificate for debils,

(This option appll* to fixed annulties and fie Guaranteed lnterest Account on Re/olutlon Value ll and Rarolution Exta ll only. lf the

ffi;;d' "
available interest in your contract/certlflcate ls greeter than th6 contract/certificate fiee amount, sunender charges may apply.)
'oi'ffi "
;.'Ei ffiilii f;ii'-witiif d;f;;i;f;;piil;if f;'i'rif
(Renarral Amount wlthdrawals apply to fixed annulties and fixed sub-account, lf mly one payment has been made to $e contract, your
ontrac wlll be fully sunendercd. Appllcable fees and sunender darges may apply.)*
'For 6PA Choke ald Perfonna Plus fixd annuldc 5 yarr rcnaryal amoufi wlfidraarals can be $bnltbd tnm the dry pu recelved pur rcnaival
lct[v Foccii€d on your annfuesary md undl 30 days anrt $e r€na /al hu ocorn€d.

081 0;1 3071 t Paoe I ol4

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