FULL OR PARTIAL WITHDRAWAL REQUEST INSTRUCTIONS …

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FULL OR PARTIAL WITHDRAWAL REQUEST INSTRUCTIONS FIXED/VARIABLE ANNUITIES

ReliaStar Life Insurance Company (Home Office: Minneapolis, MN) ReliaStar Life Insurance Company of New York (Home Office: Woodbury, NY) (the "Company") Members of the Voya? family of companies Customer Service: PO Box 1559, Hartford, CT 06144-1559 Phone: 877-884-5050

Use this form to request a withdrawal under the provisions of your annuity contract. Do not use this form to request a rollover, transfer, or exchange to another company. Please follow instructions to avoid delays in processing your request. A distribution is a tax reportable event that may not be reversed. Check boxes are provided below to guide you as you complete each section of the form.

c Good Order Please refer to this section of the form for important information. For Employee Retirement Security Income (ERISA) plans only, complete and attach a Spousal Consent form. If the appropriate documentation or information is not received, your request may be considered not in good order, e.g., Hardship withdrawal documentation. Future dated requests will not be accepted.

c RETURN COMPLETED FORMS Complete the form and mail or fax it to the Customer Service. Choose only one submission method. Multiple submissions may result in processing delays and/or duplicate withdrawals.

c CONTRACT OWNER INFORMATION Please print clearly and complete the information requested in its entirety. If you are an Alternate Payee you are not required to complete this section.

c ALTERNATE PAYEE INFORMATION Complete this section if you are an Alternate Payee requesting a withdrawal due to a Qualified Domestic Relations Order.

c WITHDRAWAL AMOUNT Select option A, B, or C and specify the applicable dollar amount or percentage. The Amount Available Free of Withdrawal Charge option refers to the free amount as defined by the contract or prospectus. Please review your contract and/or prospectus for detailed information regarding withdrawal charges and other withdrawal provisions, as some products limit the number of withdrawals that can be requested. Net or Gross Options ? Select one option if you are requesting a Partial Withdrawal or Hardship Withdrawal.

c PARTIAL WITHDRAWAL TO REPAY OUTSTANDING LOAN(S) Complete this section only if you are requesting a Partial Withdrawal and want to repay an active or defaulted outstanding loan balance(s) with amounts deducted from your contract value. If completing this section, do not complete section 3.

c WITHDRAWAL CHARGE/MARKET VALUE ADJUSTMENT ACKNOWLEDGMENT Prior to processing your request, we require written acknowledgement of any withdrawal charge and/or market value adjustment of $500 or more. If not provided, your request will be returned for completion and re-submission.

c VARIABLE ANNUITY FUND SELECTION FOR PARTIAL WITHDRAWALS If you have a variable annuity contract and wish to have your partial withdrawal from a specific investment option, you may do so by specifying in this section.

c REASON FOR WITHDRAWAL Complete this section if the contract is a 403(b) or 401(a), or if the withdrawal is subject to a waiver of withdrawal charge due to disability or termination of employment as defined by the contract or prospectus. Also complete this section if you are requesting a withdrawal to repay a loan on your contract.

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c EMPLOYER CONTRIBUTIONS This section is to be completed by the Plan Sponsor or Third Party Administrator (TPA) for 403(b) contracts subject to ERISA or that have Employer contributions subject to vesting. Contact your Employer to verify if your plan is subject to ERISA or has Employer contributions subject to vesting.

c TAX WITHHOLDING Please read the Tax Withholding section carefully for important information. Read the attached State Income Tax Withholding Notification to determine your available state withholding options.

c CONTRACT OWNER, SPOUSE AND ALTERNATE PAYEE AUTHORIZED SIGNATURES AND TAX WITHHOLDING CERTIFICATION The Owner's or Alternate Payee's, and if applicable the Joint Contract Owner and/or Spouse's signature is required on Page 6. If the Owner lives in a community property state (AZ, CA, ID, LA, NM, NV, TX, WA, WI), the Spouse's signature is required.

c Conservatorship/Guardianship and Date The Conservator/Guardian signature is required on page 7 if there is an active Conservatorship/Guardianship on file.

c EMPLOYER, PLAN SPONSOR OR NAMED FIDUCIARY AUTHORIZED SIGNATURE AND CERTIFICATION and THIRD PARTY ADMINISTRATOR AUTHORIZED SIGNATURE AND CERTIFICATION All 403(b) and 401(a) withdrawals will require certification and signature by your Employer or an authorized Third Party Administrator with few exceptions. Please contact your Employer, Plan Administrator, or TPA for their authorization and signature in section 12 and/or 13 before submitting your form.

Mail or fax your completed form to Customer Service. Keep a copy for your records.

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FULL OR PARTIAL WITHDRAWAL request FIXED/VARIABLE ANNUITIES

ReliaStar Life Insurance Company (Home Office: Minneapolis, MN) ReliaStar Life Insurance Company of New York (Home Office: Woodbury, NY) Members of the Voya? family of companies (the "Company") Customer Service: PO Box 1559, Hartford, CT 06144-1559 Phone: 877-884-5050

GOOD ORDER

Use this form to request a withdrawal under the provisions of your annuity contract. Do not use this form to request a rollover, transfer, or exchange to another company.

All transactions will be processed upon completion and receipt of this form and any other required document in good order. Good order is defined as receipt of any required information at our Service Center accurately and entirely completed, with any applicable signatures. If this form is not received in good order, including any required Employer, Plan Sponsor, or Third Party Administrator signature, a new form will be sent to you for completion and re-submission. If additional required documents are not properly executed and received within 30 days of receipt of the initial documentation, the entire submission will be closed and new paperwork will be required. To allow adequate time for processing and reporting of your distribution in the current tax year, please return this form in good order by December 15. Sections 12 and 13 are not applicable to IRA or Non-qualified annuity contracts. For ERISA Plans only, complete and attach a Spousal Consent form.

Reminder to Insurance Producer regarding New York Issued Annuity Contracts: Before making any recommendation, you must have adequate knowledge of the transaction you're recommending and provide your client with the relevant features of the annuity contract and potential consequences of the transaction, both favorable and unfavorable. If you have any questions about the annuity contract or transaction prior to making a recommendation, please contact the Company.

RETURN COMPLETED FORMS

Choose only one submission method. Multiple submissions may result in processing delays and/or duplicate withdrawals.

Important Note: All 403(b) and 401(a) withdrawals will require signature and certification by your Employer or an authorized Third Party Administrator in section 12 or 13 with few exceptions. Please contact your Employer or Plan Administrator for their signature and certification before submitting your form to the following address or fax number.

Regular Mail:Overnight Delivery:

Customer Service

Customer Service

PO Box 1559

One Orange Way

Hartford, CT 06144-1559

Windsor, CT 06095

Fax: Customer Service Toll-Free Fax: 800-382-5744

1. Contract owner information (Please print.)

Contract Number (Required)

(Financial transactions require a separate form for each contract.)

Contract Owner Name (Required)

SSN/TIN (Required)

c Check here if the address provided below is your current permanent mailing address. We will update our records to reflect this address if not currently on file.

Address (Required)

City

State

ZIP

Phone

If the above box is not checked and the address provided above does not match the address we have on file, your request will be considered not in good order and a new form will be required.

Resident state for tax purposes:

(If your current physical and/or mailing address is outside of your

state of legal residence for tax purposes, please enter your tax state here and in section 9.)

Joint Contract Owner Name MAIL CHECK TO: c Above address c Alternate address (Please complete the following.)

SSN/TIN (Required)

Address

City

State

ZIP

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2. ALTERNATE PAYEE information (Please print. Complete this section if you are an alternate payee requesting a withdrawal due to a Qualified Domestic Relations Order.)

Contract Number (Required)

Alternate Payee Name (Required)

SSN/TIN (Required)

Address (Required)

City

State

ZIP

Phone

Resident state for tax purposes:

(If your current physical and/or mailing address is outside of your

state of legal residence for tax purposes, please enter your tax state here and in section 9.)

3. Withdrawal amount (Select one option. Continue to section 4 if requesting a Partial Withdrawal to repay loans. Do not complete this section if completing section 4.)

Minimum withdrawal limits apply. Any withdrawal may be subject to a withdrawal charge and/or positive or negative market value adjustment (MVA). Please refer to your contract for more detailed information regarding the impact of withdrawals from your annuity.

If the amount available for withdrawal is less than the dollar amount you are requesting, the transaction will be processed for the maximum amount available.

c A. Partial Withdrawal (Do not complete this section to request a Partial Withdrawal to repay an outstanding loan. Select one.)

c Specific Dollar Amount $ _______________________

c Percentage of Contract Value _________%

c Amount Available Free of Withdrawal Charge $ _________________________ (If no amount is provided, the maximum amount available with no withdrawal charge will be withdrawn. If the full contract value is available free of withdrawal charge and no amount is provided, a full withdrawal will be processed.)

c B. Full Withdrawal (Prior to processing a full withdrawal, all loans will be paid with amounts deducted from your contract value. The outstanding principal loan balance and accrued interest, if not previously reported, will be reported to the IRS as a taxable distribution on IRS Form 1099-R.)

c C. Hardship Withdrawal

c Specific Dollar Amount $ _________________________

c Maximum hardship amount available

Net or Gross Options (Complete the following if you have selected option A. Partial Withdrawal or C. Hardship Withdrawal above.)

Is the amount you have requested to be the Net or Gross amount withdrawn?

c Net (Your check will be for the amount requested. Your contract value will be reduced by this amount plus any applicable withdrawal charge/MVA, federal/state tax.)

c Gross (Your check will be for the amount requested less any applicable withdrawal charge/MVA, federal/state tax. Your contract value will be reduced by the amount requested.)

If "Net" or "Gross" is not selected, we will default to processing a Gross amount.

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4. PARTIAL WITHDRAWAL TO REPAY OUTSTANDING LOAN(S) (Select A. or B. Complete this section only if you are requesting a Partial Withdrawal and want to repay an active or defaulted outstanding loan balance(s) with amounts deducted from your contract value. If completing this section, do not complete section 3.)

An eligible Reason for Withdrawal must be selected in section 7. Please note financial hardship is not an eligible reason for a withdrawal to repay a loan.

If you request a partial withdrawal to repay a loan(s), qualify for a withdrawal, and the amount available for distribution is enough to cover a) the entire outstanding loan(s) (principal plus accrued interest), and b) any withdrawal charge due and Market Value Adjustment (MVA) if applicable on the outstanding loan balance, then the sum of a) and b) is deducted from your Contract Value and the loan is paid off. The outstanding principal loan balance and accrued interest, if not previously reported, will be reported to the IRS as a taxable distribution on IRS Form 1099-R.

A withdrawal to repay an active loan is considered taxable income. Mandatory 20% federal income tax withholding applies. If applicable, any mandatory state tax will also be withheld. Consult your tax advisor for additional information.

c A. Partial Withdrawal to Repay Outstanding Loan(s). (You will not receive a check.)

I elect to: c Repay all loans.

c Repay the following Loans (5-digit loan number(s))

Note: A defaulted loan will remain outstanding on your account and will reduce the availability of future loans. A defaulted loan will continue to accrue interest which includes a spread charge owed to Voya. As a result, not repaying a defaulted loan will decrease your contract value. It remains your responsibility to continue remitting loan repayments if any of the following statements are true: this section 4 is not completed; you do not qualify for a withdrawal; you elect NOT to repay all outstanding loan balances; no loan numbers are provided; and/or the amount available for distribution is not enough to fully repay the balance of the specified loan(s). Your loan payoff may qualify for a Qualified plan loan offset. For further details, please see the section in the Special Tax Notice entitled "If you have an outstanding loan that is being offset" or refer to IRS Regulation for Qualified plan loan offset in IRC ?402(c)(3)(C)(ii).

c B. Partial Withdrawal to Repay Outstanding Loan(s) and Receive a Check. (You will receive a check. Enter the total amount of the partial withdrawal, i.e., the amount you want to receive as a check, plus the amount necessary to repay the loan(s). Example: $500 to repay loan(s) + $500 received as a net check = $1,000 entered in Specific Dollar Amount.)

Specific Dollar Amount $ __________________________

I elect to: c Repay all loans.

c Repay the following Loans (5-digit loan number(s))

Note: A defaulted loan will remain outstanding on your account and will reduce the availability of future loans. A defaulted loan will continue to accrue interest which includes a spread charge owed to Voya. As a result, not repaying a defaulted loan will decrease your contract value. It remains your responsibility to continue remitting loan repayments if any of the following statements are true: this section 4 is not completed; you do not qualify for a withdrawal; you elect NOT to repay all outstanding loan balances; no loan numbers are provided; and/or the amount available for distribution is not enough to fully repay the balance of the specified loan(s). Your loan payoff may qualify for a Qualified plan loan offset. For further details, please see the section in the Special Tax Notice entitled "If you have an outstanding loan that is being offset" or refer to IRS Regulation for Qualified plan loan offset in IRC ?402(c)(3)(C)(ii).

Net or Gross Options (Complete the following if you have selected option B. Partial Withdrawal to Repay Outstanding Loan(s) and Receive a Check above.)

Is the amount you have requested to be the Net or Gross amount withdrawn?

c Net (Your check will be for the amount requested. Your contract value will be reduced by this amount plus any applicable withdrawal charge/MVA, federal/state tax.)

c Gross (Your check will be for the amount requested less any applicable withdrawal charge/MVA, federal/state tax. Your contract value will be reduced by the amount requested.)

If "Net" or "Gross" is not selected, we will default to processing a Gross amount.

5. WITHDRAWAL CHARGE/MARKET VALUE ADJUSTMENT ACKNOWLEDGMENT (Prior to processing your request, we require written acknowledgement of any withdrawal charge and/or market value adjustment of $500 or more. If not provided, your request will be returned for completion and re-submission.)

Withdrawal Charge/Market Value Adjustment Acknowledgement

$

Amount of Withdrawal Charge and/or Market Value Adjustment incurred for the withdrawal.

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