CHECK-O-MATIC (C-O-M) ARRANGEMENT FORM FOR THE NEW …

CHECK-O-MATIC (C-O-M) ARRANGEMENT FORM FOR THE NEW YORK LIFE GUARANTEED FUTURE INCOME ANNUITY II

If you need assistance, please contact the New York Life Annuity Service Center at 1-800-762-6212 or your Representative.

IMPORTANT INSTRUCTIONS:

1. Complete this form when: (a) you are authorizing the establishment of a new C-O-M arrangement, or (b) you are changing from a savings/checking/brokerage account to another savings/checking/brokerage account, or (c) you are changing financial organizations, branches or accounts.

2. C-O-M Check-o-matic payments will be drawn as a Single Policy Draft (One premium draft per policy, drawn on the premium due date).

3. If you, as the Policyowner or Depositor, wish to terminate or change the Check-o-matic arrangement, you must notify us at least 10 days prior to your withdrawal date.

4. Complete all applicable information in the space provided below. Always print the name of the Annuitant and the policy number.

5. Complete 3rd party payor information on Page 2 if the Depositor on the account is not the Policyowner. All data is required, including the social security number or tax identification number of the 3rd party payor.

6. Signature Requirements: The Depositor(s) signature(s) as shown on the Financial Organization's records needs to be completed on page 2. The Policyowner, if not the Depositor, MUST also sign this form. If the following are Depositors or Policyowners, please be aware of the required signatures needed in each situation.

(a) Corporation as Depositor and/or Owner: This request must be signed on behalf of the corporation by two disinterested (non-Annuitant) Corporate Officers (President, Vice President, Secretary or Treasurer), with their titles.

(b) Partnership as Depositor and/or Owner: This request must be signed by two partners, with their titles as partner, other than the Annuitant. In the case of a limited partnership, we will require only the signature of a general partner, with the title of general partner. Please attach a copy of the partnership agreement.

(c) Multiple Policyowners: This request must be signed by all Policyowners.

(d) Trust as Depositor and/or Owner: This request must be signed by all trustees under the trust.

PLEASE COMPLETE THE INFORMATION BELOW: Name of Annuitant(s)

Policy Number(s)

C-O-M Premium

If more space is needed for additional policies, please enter the information on a separate piece of paper and attach it to this form. All of the information requested above must be supplied on the separate attachment for the additional policies.

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Please provide the following if you are establishing a C-O-M arrangement for the first time, or if you are changing the bank account being used for an existing C-O-M arrangement.

If you are making other changes, please check here: If using a CHECKING ACCOUNT, attach a sample check marked "VOID" here. A deposit slip is not acceptable for checking accounts.

If using a SAVINGS ACCOUNT, attach a sample deposit slip marked "VOID" here.

If using a BROKERAGE ACCOUNT, attach a sample deposit slip marked "VOID" here. Please attach the voided check or deposit slip to this shaded box with clear tape. DO NOT STAPLE.

IMPORTANT NOTE: If the VOID check or deposit slip does not have a pre-printed name on its face, we require one of the following documents to verify the account owner, or we will be unable to process your request.

? A copy of a recent bank statement (or on-line statement), showing the account number and name on the account. For your privacy, additional information such as balances and transactions should be crossed out.*

? A signed statement from your bank, on bank letterhead, verifying the account number and name on the account.*

* If a voided deposit slip cannot be provided, the bank statement or letter from your bank must include the bank name, bank address, account number, and route/transit number.

ANN8069 (11/2021)

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3rd PARTY PAYOR INFORMATION:

A 3rd party payor is someone other than the designated owner of the policy. If payment is being sent from a 3rd party payor, the 3rd party payor will need to complete the information below. If this information is not provided, your request for the Check-o-matic premium payment option cannot be processed.

Name: ____________________________________________________________________________________________________

First Name

Middle Initial

Last Name

Relationship to Policyowner: ____________________________ Company Name: ______________________________________

Social Security Number/

Date of Birth

Tax ID Number: ____________________________________ (if a Natural Person): ___________________________________

Address (Street, City, State, and Zip Code REQUIRED. P.O. Box not acceptable): ____________________________________

____________________________________________________________________________________________________________

POLICYOWNER INFORMATION:

Telephone Number: Home ( _____ )______________________ Business/Cell ( _____ ) ________________________________

HAS YOUR ADDRESS CHANGED? Yes: Use the address on the enclosed void check or deposit slip as my address of record. Yes: I will contact you to update my records.

TERMS FOR CHECK-O-MATIC ARRANGEMENTS I ask that New York Life Insurance and Annuity Corporation (NYLlAC) start a Check-o-matic arrangement to pay planned additional premiums for this policy. I have read and agree to the following terms, and acknowledge that they are not a part of any policy. 1. NYLIAC will draw monthly, quarterly, semi-annual or annual checks or other instruments to its own order, or will direct the transfer of funds, to pay planned additional premiums from the account I have designated on Page 1. 2. NYLIAC may stop the arrangement by written notice to the Policyowner or Depositor. The arrangement ends on the day NYLIAC mails the notice. 3. The Policyowner or Depositor may stop the arrangement by notifying NYLIAC. The arrangement ends on the day NYLIAC receives the notice. 4. Any correspondence sent by New York Life regarding a C-O-M arrangement will be mailed to the Policyowner of record. If payments are coming from a 3rd party payor, a notice will not be sent to that person/entity. It is the Policyowner's responsibility to advise the 3rd party payor of any changes made to the arrangement.

Indicate Check-o-matic Start Date (cannot be scheduled for the 29th, 30th, or 31st of month) _________ /_________ /_________

Month Day

Year

Indicate Check-o-matic End Date (cannot be scheduled for the 29th, 30th, or 31st of month) _________ /_________ /_________

Month Day

Year

If no end date is provided, the end date will default to the last scheduled COM payment that is not within two years of the income start date.

Indicate Check-o-matic Premium Payment Mode Monthly Quarterly Semi-Annual Annual

DEPOSITOR(S) AUTHORIZATION:

Type of Account (Check One): Checking Account Savings Account Brokerage Account

DEPOSITOR(S) SIGNATURE(S) as shown on Financial Organization's records or other Authorized Signature. If this is a Corporate account, we require the signature and title of two corporate officers.

________________________ X ______________________ ________________________ ___________________

Name of Depositor (Print)

Depositor Signature

Title of Officer, if applicable

Date

________________________ X ______________________ ________________________ ___________________

Name of Depositor (Print)

Depositor Signature

Title of Officer, if applicable

Date

POLICYOWNER(S) SIGNATURE(S): If the Policyowner is not the Depositor, the Policyowner MUST sign below.

________________________ X ______________________ ________________________ ___________________

Name of Policyowner (Print)

Policyowner Signature

Title of Officer, if applicable

Date

________________________ X ______________________ ________________________ ___________________

Name of Policyowner (Print)

Policyowner Signature

Title of Officer, if applicable

Date

Mail your completed form to:

Regular Mailing Address: NYL Annuities - TPD, Mail Code 7390, PO Box 7247, Philadelphia, PA 19170-7390 Overnight Mailing Address: NYL Annuities - TPD, 400 White Clay Center Drive, Attn: LOCKBOX # 7390, Newark, DE 19711

ANN8069 (11/2021)

Annuities are issued by New York Life Insurance and Annuity Corporation ("NYLIAC"), a Delaware Corporation. NYLIAC is a wholly owned subsidiary of New York Life Insurance Company.

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