Home / new york life your benefits resources / Full Surrender Form - New York Life Annuities

Full Surrender Form - New York Life Annuities - new york life your benefits resources

Full Surrender Form - New York Life Annuities-new york life your benefits resources

Full Surrender Form
If you need assistance, please contact the NYL Annuity Service Center at 1-800-762-6212 or your Registered Representative.
A full surrender may result in a surrender charge being deducted from the proceeds of your policy. Please contact
your Registered Representative or refer to a current prospectus before submitting this request.
You have read and understand the Distributions Under The Policy (Partial Withdrawals) and Charges and Deductions
(Surrender Charges) sections of the product prospectus for your policy.
Policy number(s) Email Address
Owner (first, middle initial, last) Social Security or Tax ID number Telephone number
Owner Mailing Address City State Zip Code
Joint Owner, if any (first, middle initial, last) Social Security or Tax ID number Telephone number
Irequest to surrender my New York Life variable annuity. I am aware that I may incur a surrender charge. I certify
that the policy has not been assigned or pledged as collateral.
Check one: Owner's Address
Checking Account (attach a voided check)
Brokerage Account
Savings Account
Alternate Address
If payments are to be deposited into a brokerage account, please complete "For Further Credit To" below.
For Further Credit To: ______________________________________________________________________________________________
Financial Institution: _______________________________________________________________________________________________
Address: _________________________________________________________________________________________________________
Address: _________________________________________________________________________________________________________
Account Holder's Name(s): _________________________________________________________________________________________
Routing Number: __________________________________________________________________________________________________
Account Number: _________________________________________________________________________________________________
Please Note: By electing Electronic Funds Transfer (EFT), you agree that all payments so made shall discharge New York Life to the
extent of the payments. In addition, you understand that because of New York Life's annuity payment processing requirements and,
if applicable, the Financial Institution's processing requirements, your EFT payment receipt date (the day the payment is available in
your account) may be later than the start date you elect (including each subsequent income payment date).
You further agree that any EFT payments made after your death shall not be held for the benefit of your estate, but shall be repaid to
the Company upon request. You authorize and direct the Financial Institution to refund to the Company an amount equal to any
payments made after your death, and if such payments shall have been credited to your account, or to the account of your estate, to
charge such account accordingly.
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.
Variable Annuities offered through properly licensed registered representatives of a third party registered broker dealer.
ANN19109 (05/2022) Page 1 of 3
Any withdrawal may result in a taxable distribution, which we will report to the IRS. In addition, a 10% IRS penalty tax may be
imposed if you receive a withdrawal prior to age 59?, unless an exception applies.
The taxable portion of your withdrawal is subject to federal income tax withholding at a flat rate of 10%, unless you tell us that
you do not want federal income taxes withheld by checking the appropriate box below. You must provide us with your Social
Security Number to make this election.
If you choose not to have federal income taxes withheld or if the amount withheld is not enough, you may be responsible for
paying estimated federal taxes to avoid an IRS penalty. You can change your withholding election at any time by filling out IRS
Form W-4P and sending it to an address listed below. If the taxable portion of a payment when added to the taxable portion
of all other payments during the year is less than $200, Federal income tax is not required to be withheld.
In addition, some states require that state income tax be withheld when federal income taxes are withheld. If you live in one of
these states, we will withhold state income taxes as required by your state.
Your signature on this form confirms that you have read this notice and make the following choice for the
transaction requested:
Check all that apply:
No income tax to be withheld.
Federal tax to be withheld _________________% Please use whole percentages. (Note: Certain states require
state income tax to be withheld when federal income tax is being withheld. See below for more information).
State tax to be withheld _________________% Please use whole percentages. (If the percentage selected is
less than your state's minimum withholding requirement, we must withhold the minimum amount).
Note: If you do not check a box or if you elect federal income tax to be withheld at a rate that is less than 10%, we will withhold
at the rate of 10% of taxable portion from future distributions, unless we are required to withhold at a higher rate.
In addition to the Federal Income tax withholding requirements, some states require withholding on policy gains when federal
income tax is withheld. As of January 1, 2018, the following states require income tax withholding when federal income tax
withholding is in effect: Delaware, District of Columbia, Iowa, Kansas, Maryland, Massachusetts, Nebraska, Oklahoma, and
Virginia. If you live in Arkansas, California, Georgia, Maine, North Carolina, Oregon, or Vermont we are required to withhold state
income tax if federal income tax withholding is in effect, unless you elect not to have state income tax withheld. If you live in
Connecticut, we are required to withhold state income tax from the taxable portion of your payments, unless you are receiving a
partial withdrawal and you provided us with a properly completed Form CT-W4P and you claim an exemption from withholding. If
you live in Michigan, we are required to withhold state income tax from the taxable portion of your payments, unless you provide
us with a properly completed Form MI W-4P and you claim an exemption from withholding. Certain exceptions and special rules
apply in some states. For more information regarding the withholding requirements applicable in your state, please consult your
tax advisor or state tax authority.
If you reside in any of the following states and request state tax withholding, you must also specify the percentage of state
tax withholding that you choose to apply to the taxable portion of the withdrawal: Alabama, Colorado, Connecticut, Hawaii,
Idaho, Illinois, Indiana, Kentucky, Louisiana, Minnesota, Mississippi, Missouri, Montana, New Jersey, New Mexico, New York,
North Dakota, Ohio, Pennsylvania, Rhode Island, South Carolina, Utah, West Virginia, and Wisconsin. In these states, if the
percentage is not specified, state tax will not be withheld.
One Indirect Rollover Per Year Rule (For Traditional, Roth, SEP, and SIMPLE IRAs): If you withdraw funds from your New York
Life IRA and plan to redeposit the funds into any IRA, please be aware that you are allowed to make only one rollover from an
IRA to another IRA in any 12-month period, regardless of the number or types of IRAs you own. If you redeposit the funds into
a New York Life IRA, you certify that: (1) the contribution qualifies as a rollover contribution pursuant to Internal Revenue Code
section 408(d)(3) and the applicable regulations, (2) you made the rollover contribution within 60 days after the day you received
the funds, and (3) including the rollover contribution, you have not made more than one indirect (i.e., 60 day) rollover from an IRA
to another (or the same) IRA in the previous 12 months regardless of the number or type of IRAs you own. If any of the above
information is not correct, you will notify New York Life within 30 days of the date of the rollover contribution.
ANN19109 (05/2022) Page 2 of 3
Owner Tax Certification:
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 (includes a U.S. resident alien), and (4) The Foreign Account Tax Compliance Act (FATCA) code
entered on this form (if any) indicating that I am exempt from FATCA reporting is correct. (Please note: if being submitted
for a U.S. policy, this last certification (4) does not apply).
Check this box if the IRS has notified you that you are subject to backup withholding.
If I am a U.S. entity, I am submitting a completed IRS Form W-9.
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.
The Internal Revenue Service does not require your consent to any provision of this document other than the certifications
required to avoid backup withholding.
Your signature confirms that all information on this form is correct.
Owner's Signature ________________________________________________________________ Date_________________________
Joint Owner's Signature ___________________________________________________________ Date_________________________
Notary Seal or Medallion Signature Guarantee required for amounts of $50,000 and above. Place Notary Seal or Medallion
Signature Guarantee below:
STATE OF ________________________________________________ COUNTY OF ___________________________________________
The foregoing instrument was acknowledged before me this____________________day of________________________, 20______
by____________________________________, who is/are personally known to me or satisfactorily proven to be the person who
executed it for the purposes therein contained.
Notary Public
Print Name
My commission expires: ___________________________________________________________________________________________
Send your completed form to:
Regular Mail: NYL Annuities - TPD, Mail Code 7390, PO Box 7247, Philadelphia, PA 19170-7390
Overnight/Express Mail: NYL Annuities - TPD, 400 White Clay Center Drive, Attn: LOCKBOX # 7390, Newark, DE 19711
Fax: Attn: NYL Annuity Service Center,, (302) 781-1780
ANN19109 (05/2022) Page 3 of 3

What benefits does New York Life offer? New York Life’s group and voluntary products offer: flexible options at a cost that fits both the strategy and budget of small businesses; a variety of voluntary and employer-paid funding options; and an option that allows first-time buyers to pay low minimum premiums.