Annuitant & Policy Information New York Life Insurance and Annuity Corporation Summary Primary Name: John Example Type of Funds: Non-Qualified Date of Birth: 02/01/1940 Payment Frequency: Annual Sex: Male Purchase Date: 02/12/2015 Joint Name: Grandchild Example Payment Start Date: 01/25/2016 Date of Birth: 02/01/2005 Illustration Expiration Date: 02/19/2015 Sex: Female Cost Basis: $100,000.00 State: Washington Premium Tax: 0.00% Tax Rate: 25% Survivor Receives 100% of Joint on Death of Either Annuitant Immediate Annuity Amounts Single Premium Amount Annual Amount Starting On 01/25/2016 Tax Free Portion of 3% Annual Increase Total Amount of Guaranteed Payments Lump Sum Death Benefit Total Payments thru Younger Annuitant Age 100 ¹ Life Only Life w/25% of Prem. DB Life w/50% of Prem. DB $100,000.00 $100,000.00 $100,000.00 $1,213.39 $1,178.10 $1,052.01 $700.97 $25,000.00 $50,000.00 $571,454.14 $555,312.09 $539,152.84 Page 1 of 10
Summary (Continued) Impact of Annual Increase Option Summary Year 1 Year 2 Year 3 Year 4 Year 5 Year 6 Year 7 Year 8 Year 9 Year 10 Year 11 Year 12 Year 13 Year 14 Year 15 Year 16 Year 17 Year 18 Year 19 Year 20 Year 21 Year 22 Year 23 Year 24 Year 25 Year 26 Year 27 Year 28 Year 29 Year 30 Annualized $1,286.13 $1,324.71 $1,364.45 $1,405.38 $1,447.54 $1,490.97 $1,535.70 $1,581.77 $1,629.22 $1,678.10 $1,728.44 $1,780.29 $1,833.70 $1,888.71 $1,945.37 $2,003.73 $2,063.84 $2,125.76 $2,189.53 $2,255.22 $2,322.88 $2,392.57 $2,464.35 $2,538.28 $2,614.43 $2,692.86 $2,773.65 $2,856.86 $2,942.57 Impact of 3% Annual Increase on Life Only Payment Option Before Tax Tax Free Portion of Annualized Cumulative Annualized $2,534.80 $3,859.51 $5,223.96 $6,629.34 $8,076.88 $9,567.85 $11,103.55 $12,685.32 $14,314.54 $15,992.64 $17,721.08 $19,501.37 $21,335.07 $23,223.78 $25,169.15 $27,172.88 $29,236.72 $31,362.48 $33,552.01 $35,807.23 $38,130.11 $40,522.68 $42,987.03 $45,525.31 $48,139.74 $50,832.60 $53,606.25 $56,463.11 $59,405.68 After tax Annualized $1,276.77 $1,305.70 $1,335.51 $1,366.20 $1,397.82 $1,430.40 $1,463.94 $1,498.50 $1,534.08 $1,570.74 $1,608.50 $1,647.39 $1,687.44 $1,728.70 $1,771.20 $1,814.97 $1,860.05 $1,906.49 $1,954.32 $2,003.58 $2,054.33 $2,106.60 $2,160.43 $2,215.88 $2,272.99 $2,331.81 $2,392.41 $2,454.81 $2,519.10 Page 2 of 10
(Continued) Summary (Continued) Impact of Annual Increase Option Summary Year 31 Year 32 Year 33 Year 34 Year 35 Year 36 Year 37 Year 38 Year 39 Year 40 Year 41 Year 42 Year 43 Year 44 Year 45 Year 46 Year 47 Year 48 Year 49 Year 50 Year 51 Year 52 Year 53 Year 54 Year 55 Year 56 Year 57 Annualized $3,030.85 $3,121.78 $3,215.43 $3,311.89 $3,411.25 $3,513.59 $3,619.00 $3,727.57 $3,839.40 $3,954.58 $4,073.22 $4,195.42 $4,321.28 $4,450.92 $4,584.45 $4,721.98 $4,863.64 $5,009.55 $5,159.84 $5,314.64 $5,474.08 $5,638.30 $5,807.45 $5,981.67 $6,161.12 $6,345.95 $6,536.33 Impact of 3% Annual Increase on Life Only Payment Option Before Tax Tax Free Portion of Annualized Cumulative Annualized $62,436.53 $65,558.31 $68,773.74 $72,085.63 $75,496.88 $79,010.47 $82,629.47 $86,357.04 $90,196.44 $94,151.02 $98,224.24 $102,419.66 $106,740.94 $111,191.86 $115,776.31 $120,498.29 $125,361.93 $130,371.48 $135,531.32 $140,845.96 $146,320.04 $151,958.34 $157,765.79 $163,747.46 $169,908.58 $176,254.53 $182,790.86 After tax Annualized $2,585.30 $2,653.50 $2,723.74 $2,796.09 $2,870.61 $2,947.36 $3,026.42 $3,107.85 $3,191.72 $3,278.10 $3,367.08 $3,458.73 $3,553.13 $3,650.36 $3,750.51 $3,853.65 $3,959.90 $4,069.33 $4,182.05 $4,298.15 $4,417.73 $4,540.89 $4,667.76 $4,798.42 $4,933.01 $5,071.63 $5,214.42 Page 3 of 10
(Continued) Summary (Continued) Impact of Annual Increase Option Summary Year 58 Year 59 Year 60 Year 61 Year 62 Year 63 Year 64 Year 65 Year 66 Year 67 Year 68 Year 69 Year 70 Year 71 Year 72 Year 73 Year 74 Year 75 Year 76 Year 77 Year 78 Year 79 Year 80 Year 81 Year 82 Year 83 Year 84 Annualized $6,732.42 $6,934.39 $7,142.42 $7,356.69 $7,577.39 $7,804.71 $8,038.85 $8,280.02 $8,528.42 $8,784.27 $9,047.80 $9,319.23 $9,598.81 $9,886.77 $10,183.37 $10,488.87 $10,803.54 $11,127.65 $11,461.48 $11,805.32 $12,159.48 $12,524.26 $12,899.99 $13,286.99 $13,685.60 $14,096.17 $14,519.06 Impact of 3% Annual Increase on Life Only Payment Option Before Tax Tax Free Portion of Annualized $106.40 Cumulative Annualized $189,523.28 $196,457.67 $203,600.09 $210,956.78 $218,534.17 $226,338.88 $234,377.73 $242,657.75 $251,186.17 $259,970.44 $269,018.24 $278,337.47 $287,936.28 $297,823.05 $308,006.42 $318,495.29 $329,298.83 $340,426.48 $351,887.96 $363,693.28 $375,852.76 $388,377.02 $401,277.01 $414,564.00 $428,249.60 $442,345.77 $456,864.83 After tax Annualized $5,361.48 $5,512.96 $5,668.98 $5,829.69 $5,995.21 $6,165.70 $6,341.31 $6,522.18 $6,708.48 $6,900.37 $7,098.02 $7,301.59 $7,511.28 $7,727.25 $7,949.70 $8,178.82 $8,414.82 $8,657.90 $8,908.28 $9,166.16 $9,431.78 $9,705.36 $9,987.16 $9,991.84 $10,264.20 $10,572.13 $10,889.30 Page 4 of 10
(Continued) Summary (Continued) Impact of Annual Increase Option Summary Year 85 Year 86 Year 87 Year 88 Year 89 Year 90 Year 91 (Age 100) Annualized $14,954.63 $15,403.27 $15,865.37 $16,341.33 $16,831.57 $17,336.52 $17,856.62 Impact of 3% Annual Increase on Life Only Payment Option Before Tax Tax Free Portion of Annualized Cumulative Annualized $471,819.46 $487,222.73 $503,088.10 $519,429.43 $536,261.00 $553,597.52 $571,454.14 After tax Annualized $11,215.97 $11,552.45 $11,899.03 $12,256.00 $12,623.68 $13,002.39 $13,392.47 Page 5 of 10
Explanations (Form 20282) The accompanying illustration is not part of the policy and does not constitute a contract. The annuity payment amount quoted is guaranteed until the Illustration Expiration Date listed on the Summary page of the illustration provided that the application is signed within fourteen (14) calendar days of the illustration prepared date and the application, illustration and funds are received in good order by the Illustration Expiration Date. If this is a 1035 exchange or transfer request, then the application must be signed within fourteen (14) calendar days of the illustration prepared date and the application, illustration, and transfer request paperwork must be received in good order by the Illustration Expiration Date and funds must be received within 60 calendar days of the illustration prepared date. Guarantees backed by claims-paying ability of the issuer. This illustration is based on the factors listed on the Summary page of the illustration, which include: age and gender of annuitant(s), purchase payment amount, selected payout option (including any optional features and election of a reduction in survivor benefit for joint life payout options), payment frequency, contract issue date, state of residence, and annuity payment start date. If there is any change in these factors, the contract may be issued with an annuity payment amount that is higher or lower than what is illustrated. The contract will be issued based on the factors listed on the application. Calculated income amounts reflect the deduction of any applicable state premium taxes. Under the terms of the contract, a pay-out option, once selected, is irrevocable after the free-look period has ended. The contract cannot be surrendered. An exclusion ratio determines the portion of each income payment that is not subject to federal income tax. The estimated tax-free portion of the payment is based on the Adjusted Investment in the contract and the Expected Return. The Adjusted Investment in the Contract is the cost of the annuity (cost basis) less the value of any refund attributable to any chosen period certain guarantee. The Expected Return is the total amount of all payments to life expectancy. After the Investment in the Contract has been paid out tax-free, the payments become fully taxable. If the source of the premium is qualified funds and the annuity is intended to satisfy the Internal Revenue Service's (IRS) Required Minimum Distribution rules, the guaranteed period chosen cannot exceed the life expectancy of the annuitant, or, if a joint and survivor annuity, the joint life expectancies of the annuitants. Life Expectancy is based on annuity tables prescribed by the IRS. If the source of the premium is non-qualified funds, any guaranteed period elected must not exceed the life expectancy of the annuitant, or, if a joint and survivor annuity, the life expectancy of the younger annuitant. Life expectancy is based on annuity tables issued by the IRS. If the source of the premium is a qualified employer retirement plan and some portion of the premium consists of employee contributions, a special "simplified method" must be used to determine the non-taxable portion of each annuity payment. The amounts shown in this illustration do not reflect this special rule detailed in IRC Section 72 (d)(1). If both annuitants die before the income payments begin, your beneficiary will only receive payments as provided under the terms of the policy. Life Only policies do not provide for any payments after the death of the annuitants. Page 6 of 10
Footnotes (Form 20282) 1. The amounts shown are for illustrative purposes only and are not a guarantee of the amount the annuitant will receive. In a single life policy, this is the projected sum of all future payments if the annuitant lives thru age 100. In a joint life policy, this is the projected sum of all future payments if the younger annuitant lives thru age 100. This projection assumes payments continue thru age 100 and will stop when the annuitant turns 101. Payments will, in fact, continue beyond age 101 if the annuitant is alive. Page 7 of 10
Withdrawal Rider Disclosure Statement for Qualified Policies and Non-Qualified Policies with a Life Only or Life with Percent Of Premium Death Benefit Payment Option A withdrawal rider is available for tax-qualified policies and for non-qualified policies with a Life Only or Life with Percent of Premium Death Benefit payment option. This withdrawal rider allows for a one-time, lump sum withdrawal from your Policy equal to 30% of the Present Value of Future Expected Payments. The Present Value of Future Expected Payments is equal to Future Expected Payments discounted to the Withdrawal Effective Date using discount rates equal to the interest rates that are, or will be, shown on the Policy Data Page, plus an Interest Rate Change Adjustment. The Future Expected Payments are the remaining payments expected to be made, based on the life expectancy of any surviving annuitants as of the Policy Date. The life expectancy is, or will be, shown on the Policy Data Page of the contract. The Interest Rate Change Adjustment, which can either increase or decrease the resulting cash withdrawal amount, is based on the change in the 10-Year Constant Maturity Treasury (CMT) rate from the time the policy is purchased to the time the Owner elects to receive the cash withdrawal. The 10-Year Treasury rate is the 10-Year CMT Series published in the Federal Reserve Statistical Release H.15. The cash withdrawal amount does not equal 30% of the premium paid for the policy. It is the present value of 30% of the expected remaining payments based on the life expectancy of the annuitant(s) of the policy. The cash withdrawal amount will not be available if it is less than $2,500. The withdrawal amounts, if shown in this illustration, are for illustrative purposes only and are not a guarantee of the amount the Owner will receive. The illustration shows two scenarios one assumes no change in the 10-Year CMT rate and the other assumes a 2% increase in the 10-Year CMT rate. Page 8 of 10
Withdrawal Rider Disclosure Statement (Continued) for Qualified Policies and Non-Qualified Policies with a Life Only or Life with Percent Of Premium Death Benefit Payment Option The cash withdrawal may be taken only once and only if the Owner is at least age 59½ at the time the cash withdrawal is taken. After the cash withdrawal is taken, future income payments will be 30% lower than they would have been had the cash withdrawal not been taken. The federal income tax treatment of an immediate annuity that contains a commutation feature (i.e., a feature that permits the lump sum withdrawal of a discounted value of future payments) is uncertain. New York Life Insurance and Annuity Corporation (the Corporation ), or alternatively, New York Life Insurance Company (the Company ), will be reporting lump sum withdrawals made in connection with the commutation feature as being fully taxable. The Internal Revenue Service may determine that the taxable amount of the annuity payments and/or withdrawals received for any year could be different than the amount reported by the Corporation or Company. In addition, the exercise of the commutation feature may: Result in the retroactive imposition of a 10% penalty tax (plus interest) on any annuity payments received before the Owner attained age 59½. Annuity payments made prior to age 59½ generally may be subject to a 10% penalty tax if the series of payments is modified (other than by reason of death or disability) before the longer of five years from the date of the first payment or age 59½. The 10% penalty tax on such annuity payments is in addition to the ordinary income tax on the taxable amount of the lump sum withdrawal. For non-qualified policies, extend the period over which an Owner may recover the investment in the contract, and may limit the Owner s ability to fully recover the investment in the contract over the annuity payment period because of the reduction or elimination of future annuity payments. The Owner should consult with his or her own tax advisor prior to exercising any commutation feature under an immediate annuity. Page 9 of 10
Withdrawal Rider Disclosure Statement (Continued) for Qualified Policies and Non-Qualified Policies with a Life Only or Life with Percent Of Premium Death Benefit Payment Option Finally, making a withdrawal from an immediate annuity purchased with non-qualified funds could negatively affect the Owner's eligibility for Medicaid long-term care benefits. The Owner should consult an attorney to understand how such a withdrawal may impact eligibility for Medicaid long-term care benefits in the future. Page 10 of 10