New York Life Insurance and Annuity Corporation
Fixed Deferred Annuity Client Profile and Policy Disclosure Form

|Owner Information |

| |Date of Birth | |
|Owner Name (First, M.I., Last) |Month |Day |Year |SS # or Tax ID # |
| | | | | …ver más…

( Yes ( No

If you answered No, please skip to the disclosures in Section 5. If you answered Yes:

1. You should be aware that using a product you own as a source of funds to finance a new purchase may be appropriate, but you may incur sales or surrender charges or other penalties. You should consult with your insurance, tax or legal advisor to determine the impact of using your existing product as a source of funds.

2. Please check the appropriate product boxes below to identify the source of funds being used for this purchase and provide specific details for each policy or account. If any pertinent policy/account information is omitted, the application will be considered incomplete and the purchase/transfer may be delayed. ← Life Insurance
| | | | |Estimated Net Surrender |Estimated Surrender |
| | | |Purchase |Value ($) |Charge ($) |
|Issuing Company |Policy Type |Policy # |Date |