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[NEW YORK LIFE MAINSTAY(R) ANNUITIES LOGO]
APPLICATION FOR
SINGLE PREMIUM DEFERRED VARIABLE ANNUITY
AT AGE 80 OR 10 YEARS
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TO NEW YORK LIFE INSURANCE AND ANNUITY CORPORATION (NYLIAC) (A DELAWARE CORPORATION) PLEASE PRINT OR TYPE
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1. WHO WILL BE THE OWNER OF THIS CONTRACT?
Name (First, M.I., Last) Date of Birth Male Female SS # or Tax ID #
Month Day Year [ ] [ ]
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Mailing Address-Street City State Zip Code
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Tel. No. (day) Tel. No. (eve) Relationship to Annuitant:
( ) ( )
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Joint Owner Name Relationship to Owner Date of Birth Male Female SS # or Tax ID #
(First, M.I., Last) Month Day Year [ ] [ ]
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2. WHO WILL BE THE ANNUITANT? IF SAME AS OWNER, CHECK HERE [ ]. (IF OTHER THAN OWNER, COMPLETE THIS SECTION.)
Name (First, M.I., Last) Date of Birth Male Female SS # or Tax ID #
Month Day Year [ ] [ ]
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Mailing Address-Street City State Zip Code Tel. No.
( )
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3. WHAT IS YOUR PREMIUM AMOUNT? (ATTACH CHECK PAYABLE TO NYLIAC, UNLESS INSTRUCTED OTHERWISE.)
Premium Amount $
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4. WHO WILL BE THE PRIMARY BENEFICIARY(IES) OF THIS CONTRACT? NOTE: COMPLETE QUESTION 7 TO NAME A CONTINGENT BENEFICIARY.
Name: Relationship to Owner: Percentage:
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Name: Relationship to Owner: Percentage:
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5. WHAT IS THE PLAN TYPE? (COMPLETE ONE PLAN.)
[ ] NON- Is this a 1035 Exchange [ ] YES [ ] NO If yes, what is the Cost Basis?
QUALIFIED (If yes, submit from 18263) $
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[ ] IRA Current Year Contribution Prior Year Contribution Transfer Amount Rollover Amount
[ ] SEP $ Year $ Year $ $
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[ ] 403(b) Transfer Amount NOTE: If this is an IRA/SEP transfer/rollover or 403(b) transfer, submit
(TSA) $ Request for IRA Transfer/Direct Rollover or 403(b) Transfer Form.
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6. IS THIS A REPLACEMENT OF A LIFE INSURANCE OR ANNUITY POLICY? (IF YES, COMPLETE THIS SECTION.)
Company Name Policy Number(s) Estimated Contract Value
$
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7. ARE THERE ADDITIONAL DETAILS?
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8. SIGNATURES I/We acknowledge receipt of a current prospectus and agree that: (1) All of the statements in this application are
true to the best of the knowledge and belief of those who made and recorded them. (2) This contract will-not become effective
unless it is delivered to the Owner while the Annuitant is living. (3) Unless otherwise indicated below, the Owner of this
contract is the Applicant. (4) Under penalties of perjury, the Taxpayer Identification Numbers provided on this application are
certified to be correct. (5) I/We understand that the annuity is not backed or guaranteed by any bank or insured by the FDIC.
BENEFITS BASED ON THE PERFORMANCE OF THE SEPARATE ACCOUNTS ARE VARIABLE AND ARE NOT GUARANTEED AS TO THE DOLLAR AMOUNT.
Signed at
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City State Date
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Applicant (Owner) Annuitant (if other than Owner) Joint Owner (if applicable)
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Agent/Reg. Representative's Signature Registered Representative (print name) Registered Representative's Tel. No.
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Registered Representative's State and License No. Reg. Representative's NYLIAC Code No.
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Broker/Dealer Name and Address Broker/Dealer Tel. No.
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[RECYCLE LOGO]
200-596AL (7/2000) Printed on Recycled Paper
