RETIREREADY SM RETIREMENT ANSWER NY VARIABLE ANNUITY. Issued by Genworth Life Insurance Company of New York

Transcription

1 RETIREREADY SM RETIREMENT ANSWER NY VARIABLE ANNUITY FORMS PACKET FOR USE IN THE STATE OF NEW YORK. Issued by 19799GERANY 01/01/06

2 CONTENTS Welcome Annotated Application Enrollment Form Allocation Form Forms Requirements Authorization to Transfer Exchange Funds Transfer Authorization Plan Information Form Certification of Trustee Powers Forms Packet Page 1 of 22

3 WELCOME TO GENWORTH FINANCIAL Thank you for choosing Genworth Financial to help meet your client s retirement needs. As a new public insurance holding company comprised of businesses from GE Financial and Genworth Mortgage Insurance, Genworth Financial is built on GE heritage. The history of the Genworth Financial family of companies dates back to We are among the largest U.S. insurance holding companies, with an expanding global presence. Built on a tradition of innovative products, customer service, and an extensive distribution network, we are beginning this new phase in our companies history with a strong framework of: * 15 million customers More than 6,400 employees Operations in 24 countries * as of 9/13/05. Whether your clients goal is to buy a home, secure their family s current lifestyle or ensure retirement income, we strive to make it easy for your client to understand what they are buying. For you, our valued representative, that means we are striving to make it easier to do business with us by providing: Exceptional tools and training Easy to understand marketing materials Support throughout the sales process This packet is provided to assist you in completing and submitting your client s variable annuity application. It is our hope that the content on the following pages will answer many of your questions. On the following pages you will find: Variable Annuity Application The appropriate application for the annuity your client has chosen has been provided. An annotated application is also included to assist you with completing the application, as well as any other forms necessary for successful completion of the application. Replacement Forms Depending on your state, replacement forms may be required when submitting a variable annuity application. The replacement forms are provided by state grid to give you the list of appropriate forms for each state. The replacement forms are also included either in this packet or separately in your kit. Portfolio Expenses A fundamental part of a variable annuity is the underlying variable portfolios. This flyer can be shared with your clients in conjunction with the brochures provided to help choose their portfolio mix. Additional Forms Depending on your client s situation, additional forms may be required. A table is provided to assist you in choosing the correct form for your client s situation. If at any time you find you need additional forms or just have a question, we are here to assist you please contact us at Forms Packet Page 2 of 22

4 RetireReady SM Retirement Answer NY Variable Annuity issued by Genworth Life Insurance Company of New York Tips for completing RetireReady SM Retirement Answer NY Enrollment Forms Stand- Alone Contracts For RetireReady SM Retirement Answer NY Stand- Alone contracts: Complete forms 19532NY and 19532BNY. Principal underwriter: Capital Brokerage Corporation 3001 Summer Street, P.O. Box , Stamford, CT Member NASD/SIPC Genworth Financial, Inc. All rights reserved. FOR BROKER/DEALER USE ONLY. NOT TO BE REPRODUCED OR SHOWN TO THE PUBLIC. [Page 1 of 4] NS19926NY 01/01/06 Forms Packet Page 3 of 22

5 Stand- Alone Contracts RetireReady SM Retirement Answer NY Stand - Alone contracts: Step 1: Complete the Variable Annuity Enrollment Form (19532NY) Step 2: Complete the RetireReady SM Retirement Answer NY Allocation Form (19532BNY) Both forms must be completed in order to process an application. A B C D E Variable Annuity Enrollment Form Form 19532NY (Page 1 of 2) A B C D E NOTE: Sections shaded in gray are pre- filled when using an illustration software tool. Ask your representative for details. 1 Indicate your client s intent to purchase RetireReady SM Retirement Answer NY as a Stand- Alone contract. 2-5 Complete Annuitant, Joint Annuitant, Owner and Beneficiary sections. Tips: Non - Qualified contracts Annuitant(s) must also be named as Owner(s) except for non- natural Owners. Qualified contracts There may be restrictions for Joint Owners and Joint Annuitants for qualified contract types. Refer to the contract and product prospectus for details. Be sure to review the RetireReady SM Retirement Answer NY contract resolutions. 6 Fill in the amount of cash submitted with the application AND/OR the expected 1035 exchange/transfer amount(s). NOTE: A maximum of 13 Scheduled Installments may be paid in advance exchanges/transfers in excess of 13 Scheduled Installments will not be accepted. 7 Mark the corresponding circle to indicate whether the contract is Qualified or Non-Qualified. For Qualified contracts, you must also mark the circle that best identifies the source of premium to be submitted. Be sure to mark only one circle and be careful not to mark outside of the circle. NOTE: Do not mark areas without a circle present, as they are not available. Additional sources may be indicated using the Other option. 8 Indicate the number of years and months until maturity using the Annuity Commencement Date provided by your client. Keep in mind it must be at least 10 years in the future. 9 Indicate which Payout Period Option your client has chosen for RetireReady SM Retirement Answer NY. NOTE: For Qualified contracts, the period certain may be dictated or restricted by your client s life expectancy. 10 Specify the monthly purchase payment your client wants to contribute OR the retirement payment your client wants to receive. Please specify only one. [Page 2 of 4] Forms Packet Page 4 of 22

6 Variable Annuity Enrollment Form (continued) Form 19532NY (Page 2 of 2) NOTE: Sections shaded in gray are pre- filled when using an illustration software tool. Ask your representative for details. F G F G 11. Be sure to have your clients read the Authorization. This section must be completed with signature(s) of the Annuitant, Joint Annuitant and/or nonnatural Owner, date(s) and the state in which the Enrollment Form is signed. The replacement question must be answered. A yes response may require additional forms. 12. If completed in the illustration software, this information will be prefilled. The replacement question must be answered and all information completed for commissions to be paid. Additional agents must be noted on a separate sheet of paper with Representative Name, Social Security number, Broker/Dealer Name, Telephone Number and percentage of Commissions. Commission Options RetireReady SM Retirement Answer NY commissions are paid during the accumulation phase (prior to the Annuity Commencement Date), and at the Annuity Commencement Date selected at issue. For commission during the accumulation phase, no selection is necessary. For commission beginning at the Annuity Commencement Date, you may choose Contract Value (CV) OR Calculated Annual Benefit/Payments (P). If an option is not selected, the default will be Contract Value (CV). Contact your Genworth Life Representative for your specific commission information. [Page 3 of 4] Forms Packet Page 5 of 22

7 H I J RetireReady SM Retirement Answer Allocation Form Form 19532BNY (Page 1 of 1) H I J NOTE: Sections shaded in gray are pre-filled when using an illustration software tool. Ask your representative for details. 14. Your client may choose to fund the contract on a monthly basis by: Submitting cash with application at least one payment is required to be submitted with application. (Your client may submit up to 13 monthly payments in advance. For Qualified contracts, the monthly purchase payments cannot exceed annual allowable maximums. Your clients should consult their tax advisor.) Drafting first monthly payment your client must complete Bank Information section. Use this area to indicate any special Purchase Payment instructions. 15. Indicate whether future payments will be made by EFT or by check. If using EFT, your client must provide the bank information. 16. Provide bank information if your client has chosen EFT payments and be sure to have the account holder sign and date authorizing these transfers. Do not forget to attach a voided check from the corresponding account. [Page 4 of 4] Forms Packet Page 6 of 22

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9 Variable Annuity Enrollment Form 666 Third Avenue, 9th Floor, New York, NY Confirmation # Please print using black ink. 1. Select One RetireReady SM Retirement Answer only or RetireReady SM Retirement Answer & Funding Annuity (information below will apply to both contracts.) 2. Individual Annuitant (Last, First, M.I.) Owner will be the same unless Owner is non-natural Owner. If Owner is not a U.S. citizen, attach IRS W-9 form; if non-resident alien, attach W8-BEN form instead. Gender M Date of Birth (mm-dd-yyyy) Social Security No. Telephone No. F Mailing Address City State Zip Code 3. Individual Joint Annuitant (Last, First, M.I.) Joint Owner will be the same unless Owner is non-natural Owner. Gender M Date of Birth (mm-dd-yyyy) Social Security No. Telephone No. F Mailing Address City State Zip Code 4. Owner Complete only if Owner is non-natural; Name of Entity or Trust and Trustee Date of Trust (mm-dd-yyyy) Tax ID No. Telephone No. Mailing Address City State Zip Code 5. Primary Beneficiary (Last, First, M.I. or Name of Trust and Trustee) Allocated % Gender M F Date of Birth or Trust Relationship to Social Security Date (mm-dd-yyyy) Annuitant No. or Tax ID No. (optional) Additional Beneficiary (Last, First, M.I. or Name of Trust and Trustee) Allocated % Primary Gender M Contingent F Date of Birth or Trust Relationship to Social Security Date (mm-dd-yyyy) Annuitant No. or Tax ID No. (optional) Beneficiaries may be changed at any time by the Owner, unless made irrevocable by checking this circle: Use a separate sheet signed by Owner(s) for additional beneficiaries. 6. Purchase Payment Information Genworth Life of New York reserves the right to only accept purchase payments within our minimum and maximum guidelines. Total Amount Submitted With Enrollment Form: $ Expected 1035 Exchange or Transfer Amount(s): $ 7. Contract Type: Please select one contract type and the appropriate source of premium. Non-Qualified Qualified Contract Type Source of Premium: (Select One) IRA SEP IRA* Roth IRA TSA/403(b) Annuity Pension** Profit Sharing/401(k)** Other Qualified Plan * Does not apply to reinvested SEP amounts. Your SEP is an IRA. Check applicable Transfer, Rollover or Conversion circle in this Section. ** Investment Only New Contribution for Tax Year Recharacterization: Yes No Direct Transfer Customer Rollover Direct Rollover From 401(a) Gov t 457 Plan 401(k) TSA/403(b) Other Conversion/Reconversion Other 8. Annuity Commencement Date (ACD) Income Payments begin in years months from contract date. (Minimum of 10 years.) 9. Payout Period Option for RetireReady SM Retirement Answer: Life with year Period Certain. (10-50 years in 5 year increments; if no option chosen, Contract will be for Life with 10 year Period Certain.) 10. Specify One for RetireReady SM Retirement Answer: Monthly Scheduled Installment OR Guaranteed Minimum Income Payment You Wish to Pay $ You Wish to Receive $ 19532NY 4/2003 Page 1 of 2 To order use stock no 19532NY 01/01/06 Forms Packet Page 8 of 22

10 Variable Annuity Enrollment Form 666 Third Avenue, 9th Floor, New York, NY Confirmation # Please print using black ink. 11. Owner Signature(s) and Authorization READ CAREFULLY and COMPLETE ALL INFORMATION All statements made in this enrollment form are true to the best of my/our knowledge and belief, and the answers to these questions, together with this agreement, are the basis for issuing the contract(s). I/we agree to all terms and conditions as shown. I/we agree that no one, except a President or Vice President of the Company can change the annuity contract(s). Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance may be guilty of a crime and may be subject to fines and confinement in prison. 1. Will the proposed annuity(ies) replace and/or change any existing annuity or insurance contract(s)? Yes No I/we verify our understanding that ALL PAYMENTS AND VALUES PROVIDED BY THE CONTRACT(S), WHEN BASED ON THE INVESTMENT EXPERIENCE OF THE SUBACCOUNTS, ARE VARIABLE AND NOT GUARANTEED AS TO DOLLAR AMOUNT. I/WE HAVE RECEIVED, AND UNDERSTAND THE PROSPECTUSES FOR THIS ANNUITY(IES). I/we understand that the contract value(s) may increase or decrease depending on the investment return of the Investment Subaccount(s). I/we understand that all Scheduled Installments must be made in a timely manner and all withdrawals from the Investment Subaccount(s) in RetireReady SM Retirement Answer must be repaid with interest within one year of withdrawal in order for my Guaranteed Minimum Income Payment to remain in effect. I/we understand that an Allocation Form must be completed and it is incorporated by reference. I/we believe this contract(s) and Investment Allocations will meet my insurance needs and financial objectives. Signature of Date (mm-dd-yyyy) Individual Annuitant Signature of Individual Date (mm-dd-yyyy) Joint Annuitant Signature and Title of Date (mm-dd-yyyy) Non-natural Owner State in Which Enrollment Form Signed New York 12. Representative(s) Information and Signature(s) READ CAREFULLY and COMPLETE ALL INFORMATION Do you have reason to believe that the proposed annuity(ies) will replace any existing annuity or insurance contract(s)? Yes No All Regulation 60 requirements must be fulfilled prior to completing this application. Representative Name* Social Security No. or Tax ID Broker/Dealer Name Branch # At ACD CV P Address City State Zip Code Telephone No. Fax No. Address Representative Signature * Use a separate sheet for split commissions. Please provide all agent information listed above including commission split percentages. Regular Mail P.O. Box Richmond, VA For Inquiries an/or Questions Internet: genworth.com Toll free: (800) Overnight Delivery 6610 West Broad Street Richmond, VA NY 4/2003 Page 2 of 2 To order use stock no 19532NY 01/01/06 Forms Packet Page 9 of 22

11 RetireReady SM Retirement Answer Confirmation # Please print using black ink. 13. Purchase Payment Instructions Monthly Scheduled Purchase Payment Monthly Purchase Payment $ Indicate number of months paid in advance* x =.....$ OR (Includes one required payment) Draft first Scheduled Purchase Payment (Complete Bank Information Section below) Total Amount Submitted with Enrollment Form $ (This amount should equal amount completed in section 6) Other Special Purchase Payment Instructions: *Maximum of 13 Scheduled Installments may be paid in advance. 14. Monthly Scheduled Purchase Payment Instructions Future Scheduled Purchase Payments Electronic Funds Transfer (EFT) Monthly Check Payments Other Bank Information Section must be completed. Additional monthly fee applies. 15. Bank Information - Complete for Electronic Funds Transfer Bank Name Draft Date (Contract Date unless otherwise specified.) Monthly Draft Amount $ City State Zip Code Bank Telephone Number Type of Account Checking Account Bank Account Number Bank ABA or Routing Number Savings Account I authorize and direct, and any financial institution it uses, to initiate automatic fund transfers, or other forms of pre-authorized check withdrawals (debits) from my account at the financial institution listed above, and to initiate deposits (credits) if necessary for any withdrawals made in error. I acknowledge that the origination of the Automatic Payment Plan transactions to my account must comply with the provisions of U.S. law. This authority is to remain in full force and effect until the Company has received notification from me of its termination in such time and in such manner as to afford the Company reasonable opportunity to act on it. Signature of Account Holder Date Attach voided check below 19532BNY 01/01/06 Page 1 of 1 Forms Packet Page 10 of 22

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13 RETIREREADY SM RETIREMENT ANSWER NY FORM REQUIREMENTS Retirement Answer NY Variable Annuity Issued by Genworth Life Insurance Company of New York Application Forms Enrollment Form Retirement Answer Allocation Form Definition of Replacement* 19532NY 19532BNY NY-1887 Enrollment form must be accompanied by 19532BNY. Must be used for all NY contract purchases. Must be used for all NY contract purchases. New Business 1035 Exchanges Qualified Plan Transfers Annuitizations Principal underwriter: Capital Brokerage Corporation (dba GE 3001 Capital Summer Brokerage Street Corporation P.O. Box in MN, Stamford, IN, CT NM and TX) 3001 Member Summer NASD/SIPC Street P.O. Box Genworth Stamford, Life CT & Annuity and Capital Brokerage Member Corporation NASD/SIPC are Genworth Financial Genworth Life companies, & Annuity formerly and Capital Brokerage GE Corporation Financial. are Genworth Financial GE companies, is a trademark formerly of the General Electric GE Financial. Company and is used with permission. GE is a trademark of the General Electric Company and Genworth is used with Financial, permission. Inc. All rights reserved Genworth Financial, Inc. All rights reserved. Replacement Notice* Authorization to Transfer Qualified Funds IRC Section 1035 Exchange Form Fund Transfer Authorization Plan Information Form NY NY 14209NY 14215NY 14213NY Must be used when replacing life insurance policy(ies) or annuity(ies). Use when Qualified Plan Contract Type is selected AND a transfer is taking place. Use for non-taxable transfers. Liquidation Authorization for a Certificate of Deposit or Mutual Fund Account to a Non-Qualified Annuity. Use to certify that minimum distribution requirements are being met. * Not included in forms packet. To order, contact your Company Representative. Please note: Retirement Answer NY allows monthly purchase payments only. Clients may pre-pay up to 13 monthly payments (at age 70) (at age 70) (at age 70) 19823GERANY 01/01/06 FOR BROKER/DEALER USE ONLY. NOT TO BE REPRODUCED OR SHOWN TO THE PUBLIC. Forms Packet Page 12 of 22

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15 Authorization to Transfer Qualified Funds 666 Third Avenue, 9th Floor New York, NY Current Trustee/Custodian Mailing Address Daytime Phone Number I authorize the transfer of funds from: 401(a) or 401(k) plans 403(b) TSA 408(b) Traditional IRA Other Into: a new policy to be issued by. an existing policy, #, issued by. I also authorize you to release directly to any information relevant to this transfer. Owner Address City State Zip Telephone: Home Business ( ) ( ) Social Security/Tax ID Number Account Number(s) Amount to be transferred (if less than entire balance) $ $ My policy is lost (if applicable) Entire balance Please make the check payable to and mail to the address at the bottom of this form. Contact the Variable Products Service Center at (800) if anything additional is needed to complete this transfer. Owner/Trustee Signature Date Letter of Acceptance (For Home Office use only) Please be advised that will accept the proceeds from the account referenced above, to be applied to the following account for the named participant: 401(a) 403(b) TSA 408(b) Traditional IRA Other Authorized Signature For Date Regular / First Class Mail: P.O. Box Richmond, VA NY 01/01/06 Page 1 of 1 Complete a separate form for each company. Forms Packet Page 14 of 22

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17 IRC Section 1035 Exchange Form 666 Third Avenue, 9th Floor New York, NY This form can be used to accomplish a FULL or a PARTIAL exchange of policies pursuant to IRC Section A FULL exchange requires that the existing policy be absolutely assigned to (Genworth Life of New York). A PARTIAL exchange does not require an assignment. It is a partial withdrawal from the cash value account in the existing contract. The check for the withdrawn funds must be made payable to Genworth Life of New York. Complete the requested information concerning the existing contract, check the appropriate circle, and date, sign, and witness this form. Send it in with the existing contract attached. The state of New York requires that additional forms be completed with all exchanges. Representatives may order these through normal channels using form # K14700VARNY. Policy Information Existing Policy/Contract Number Name of Insured (Annuitant) [First, Middle, Last] Name of Owner [First, Middle, Last] Name of Insurer (Company) Company Address City, State and Zip Exchange Requested If neither circle is checked, a full 1035 exchange will be assumed. FULL EXCHANGE. In exchange for a new life insurance policy or annuity contract described in the application for such new policy or contract (the Application), I hereby assign and transfer without exception, limitation, or reservation to Genworth Life of New York, all assignable benefits, interest, property and rights in the above numbered policy or contract (Assigned Policy). Furthermore, I understand that by executing this Assignment, I irrevocably waive all rights, claims and demands under the Assigned Policy. I understand that if Genworth Life of New York approves the Application, Genworth Life of New York will surrender the Assigned Policy and request the proceeds. If and when received, the proceeds will be applied as all or part of the premium payment for the new policy or contract. For purposes of this assignment, the Application shall be considered approved by Genworth Life of New York at the time that Genworth Life of New York submits the Assigned Policy to the insurer named above for surrender. I understand that Genworth Life of New York will not treat this assignment as the equivalent of a cash payment and that no part of the value of the Assigned Policy will be treated as a premium payment under the new policy or contract until it is actually received by Genworth Life of New York. Simultaneously with this assignment, I also revoke all existing beneficiary designations under the Assigned Policy and designate Genworth Life of New York, its successors or assigns as beneficiary of any death benefits that may become payable under the Assigned Policy. PARTIAL EXCHANGE. With respect to the above numbered policy, I wish to obtain a partial withdrawal from the policy/contract in the amount of $. The check should be made payable to Genworth Life of New York. I understand that partial surrender charges may apply. I do not want federal income tax withheld because I intend this transaction to be a partial exchange under IRC Section I expressly represent that the sole purpose is to effect an exchange (Full or Partial) of a life insurance policy or annuity contract under Section 1035(a) of the Internal Revenue Code and that Genworth Life of New York has made no representations concerning any tax treatment of this transaction. I understand and agree that Genworth Life of New York has no responsibility nor liability for the validity of this transaction or for my tax treatment under Section 1035(a) of the Internal Revenue Code or otherwise. No person, firm, or corporation other than myself and the insurer which issued the above numbered policy, has an interest in said policy. No proceedings in insolvency or bankruptcy have been instituted by or against me. My policy is attached. I have lost my policy. Signed this day of, 20 at (City, State) Witness Policyowner Regular / First Class Mail: Annuity New Business Department P.O. Box Richmond, VA NY 01/01/06 Page 1 of 1 Forms Packet Page 16 of 22

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19 Transfer Authorization 666 Third Avenue, 9th Floor New York, NY Liquidation Authorization for a Certificate of Deposit or a Mutual Fund Account to a Non-Qualified Annuity Financial Institution/Mutual Fund Account/Certificate Number Address Account/Certificate Owner s Name City State Zip Additional Names (if more than one owner) Daytime Phone Number Owner s Social Security/Tax ID Number Additional Social Security/Tax ID Number (for additional owners, if any) I hereby request and direct the following action to be taken to transfer the proceeds of the account/certificate identified above: Liquidate certificate of deposit (CD attached) On the maturity date of (must not be more than 90 days after the date this form is signed). Upon receipt of this request Liquidate mutual fund account (copy of recent statement attached). I am aware that surrender/withdrawal penalties may apply to this liquidation and that income tax consequences may result. I have been advised to contact my tax advisor. I authorize the above liquidation and the transfer of the net proceeds to. Please make the check payable to:, FBO (owner s name(s) from above), and send to the address at the bottom of this form. The date these proceeds are received by will be the issue date of the annuity for which I have applied. Owner s Signature City/State Date Additional Owner s Signature (if any) City/State Date Signature Guarantee (Required for mutual fund liquidations.) TO: The Financial Institution/Mutual Fund will accept the transfer requested above. By: Name Title Date Regular / First Class Mail P.O. Box Richmond, VA NY 01/01/06 Page 1 of 1 Forms Packet Page 18 of 22

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21 Plan Information Form 666 Third Avenue, 9th Floor New York, NY Information for: Qualified Pension and Profit-Sharing Plan Participants/Trustees who Hold/Purchase Annuities in the Plan Owners of Individual Retirement Annuities (IRAs) 403(b) Plan Participants who Hold/Purchase Annuities The Internal Revenue Service imposes a minimum distribution requirement on qualified retirement programs, including: Pension-qualified annuities Annuities sold to qualified pension or profit-sharing plan trustees Annuities purchased through a 403(b) plan Annuities sold as individual retirement annuities Annuities sold to custodians of individual retirement accounts MINIMUM DISTRIBUTION REQUIREMENTS Distributions from an individual retirement account or an individual retirement annuity must begin by April 1 of the year after the year in which the owner/ participant* reaches age For other qualified plans, distributions to owners/participants who are not 5% owners of the employer sponsoring the plan must commence by April 1 of the calendar year following the calendar year in which the owner/participant* attains age or retires, whichever is later. Owner/participants* who are 5% owners of the sponsoring employer must begin to receive distributions by April 1 of the year after the year in which they reach The owner/participant who funds one of these plans with a (Genworth Life of New York) annuity may choose to satisfy these requirements in one of the following two ways: by receiving periodic payments from the annuity beginning by April 1 of the year following the year in which he/she becomes , or by receiving the entire surrender value of the annuity by that April 1 date. A surrender charge may apply to either option. The required minimum distribution for the owner/participant must be calculated for total assets in the qualified plan. Where the annuity contract is only one of the plan assets, the required minimum distribution need not be made pro rata from each asset. *If the owner is a trustee, then the beneficial owner s age applies. I certify that I have read the statements above and I understand the minimum distribution requirements applicable to my qualified retirement plan. I also represent that I am meeting the minimum distribution requirements for the next 12 months as follows (check one): through distributions from other assets held by my qualified plan, rather than from my Genworth Life of New York annuity contract, or through distributions from plan assets that may include my Genworth Life of New York annuity contract. I understand that a surrender charge may apply to such distributions from my Genworth Life of New York annuity contract. Annuity Owner Name (Print or Type) Title Signature of Annuity Owner Date Return one copy with application Give one copy to Client PLEASE MAIL TO: P.O. Box Richmond, VA NY 01/01/08 Page 1 of 1 Forms Packet Page 20 of 22

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23 Certification of Trustee Powers For use with Non-Qualified Variable Annuity Contracts Variable Annuity SERVICE ADDRESS: Genworth Life and Annuity Insurance Company P.O. Box Richmond, VA EXPRESS MAIL: Genworth Life and Annuity Insurance Company 6610 West Broad Street Richmond, VA I/we the undersigned Trustee(s) certify as follows: Trust Information 1. The full title of the trust to which this Certification applies is: 2. The date of the trust is: Example: Jones Family Trust 3. The date of the latest Trust Amendment, if any, is: 4. The Grantor(s) of the Trust is/are: 5. Type of Trust: Irrevocable Revocable Charitable Remainder Trust (CRT) 6. Employer Identification Number (EIN) or 7. If this is a Grantor Trust (defined by Section 671 of the Internal Revenue Code) please provide the Grantor s Social Security Number (SSN) : Authorized Individuals 8. The Trust Agreement authorizes you to accept orders and other instructions from: (please check one) a. any one Trustee independently b. both co-trustees must authorize c. multiple Trustees all must authorize Investments Permitted Authorized Transactions 9. By signing below, I/we certify that: A. I/we have the power under the Trust Agreement and applicable law to purchase and exercise all ownership rights, privileges, options and benefits under the annuity contract, including but not limited to the following: withdrawals, surrenders, transfers, and the ability to change the beneficiary. I/we understand and agree that when the Trust, as Owner, exercises ownership rights under the contract or the Trust, as Beneficiary, claims benefits under the contract, the Company will have no obligation to verify that a Trust is in effect or that the Trustee is acting within his/her authority. B. I/we, the Trustee(s), jointly and severally indemnify and hold the Company harmless from any liability for effecting transactions of the types specified in Item 9 above, as long as the Company acts pursuant to my instructions. Further, the undersigned Trustee(s) agree that the Company shall not be responsible for the application or disposition of the proceeds of the said contract by the Trustee, and payment to the Trustee of the proceeds shall fully discharge the Company from all liability under the contract to the extent of such payment. C. I/we agree to inform you in writing of any change in the composition of the Trustees, or any other event which could materially alter the Certifications made above. Trustees 10. I/we hereby certify that the undersigned are all of the Trustees: (ALL TRUSTEES MUST SIGN IN FIDUCIARY CAPACITY; ATTACH EXTRA PAGE IF NECESSARY.) Example: John Jones, Trustee Print Name Signature Date, Trustee, Trustee Form No. GEFA-CTPVANY 01/01/06 Forms Packet Page 22 of 22

24 RetireReady SM Retirement Answer NY Variable Annuity Issued by: Genworth Life Insurance Company of New York 666 Third Avenue, 9rd Floor New York, NY genworth.com Principal underwriter: Capital Brokerage Corporation (dba Genworth Financial Brokerage Corporation in MN, IN, NM, and TX) 3001 Summer Street PO Box Stamford, CT Member NASD/SIPC Genworth Life of New York and Capital Brokerage Corporation are Genworth Financial companies, formerly GE Financial. GE is a trademark of the General Electric Company and is used with permission. Member: National Association for Variable Annuities Genworth Financial, Inc. All rights reserved.