EXHIBIT 5(b)(ii)
AMERICAN GENERAL LIFE INSURANCE COMPANY OF NEW YORK ("AGNY")
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Complete and return to: A Subsidiary of American General Corporation
Annuity Administration ---------------------------------------------
P.O. Box 1401 Syracuse, New York GENERATIONS(TM)
Xxxxxxx, XX 00000-0000 ===============
(000) 000-0000 SERVICE REQUEST Variable Annuity
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[X] CERTIFICATE 1.| CERTIFICATE #:___________________________________________ ANNUITANT:___________________________________
IDENTIFICATION |
| CERTIFICATE OWNERS(S):_________________________________________________________________________________
(COMPLETE SECTIONS |
1 AND 15 | ADDRESS:_______________________________________________________________________________________________
FOR ALL REQUESTS.) |
| [ ] CHECK HERE IF
INDICATE CHANGE OR | CHANGE OF ADDRESS _____________________________________________________________________________________
REQUEST DESIRED BELOW. |
| S.S. NO. OR TAX I.D. NO._________________________________ PHONE NUMBER: ( )______ - _______________
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[ ] NAME 2.| [ ] Annuitant* [ ] Beneficiary* [ ] Owner(s)*
CHANGE | (*DOES NOT CHANGE ANNUITANT, BENEFICIARY OR OWNERSHIP DESIGNATION.)
|
| ______________________________________________________________________________________________________
| FROM (FIRST, MIDDLE, LAST) TO (FIRST, MIDDLE, LAST)
|
| _________________________________________ _________________________________________________
| Reason: [ ] Marriage [ ] Divorce [ ] Correction [ ] Other (ATTACH CERTIFIED COPY OF COURT ORDER)
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[ ] DUPLICATE 3.|
CERTIFICATE | I/we hereby certify that the certificate for the listed number has been
| [ ] LOST [ ] DESTROYED [ ] OTHER____________
| Unless I/we have directed cancellation of the certificate, I/we request that a Certificate of Lost
| Certificate be issued. If the original certificate is located, I/we will return the Certificate of
| Lost Certificate to AGNY to be voided.
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[ ] BENEFICIARY 4.| PRIMARY CONTINGENT
CHANGE |
|
|
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THIS SECTION IS | This change of beneficiary has been approved by AGNY at its Administrative Office, and presentation of
FOR ADMINISTRATIVE | the Certificate for endorsement has been waived.
OFFICE USE ONLY |
| DATE OF APPROVAL:_______________________________By:___________________________________________________
| American General Life Insurance Company of New York
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[ ] AUTOMATIC 5.| ___________ By initialing here, I authorize AGNY to collect $____________________________ (min. $100)
ADDITIONAL | starting month/day ________________________________ by initiating electronic debit entries
PREMIUM PAYMENT | against my bank account with the following frequency:
OPTION | [ ] Monthly [ ] Quarterly [ ] Semiannually [ ] Annually
| (Attach voided check to Service Request.)
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[ ] DOLLAR COST 6.| Dollar cost average [ ] $________ OR [ ] _________% (whole % only) Begin Date:______/________/______
AVERAGING | Taken from the: [ ] Money Market OR [ ] 1-Year Guarantee Period MM DD YY
| Frequency: [ ] Monthly [ ] Quarterly [ ] Semiannually [ ] Annually
| Duration: [ ] 12 months [ ] 24 months [ ] 36 months [ ] 48 months [ ] 60 months
| to be allocated to the following division(s) as indicated. (Use only dollars OR percentages.)
| Asian Equity (140) _________ High Yield (134) _________
| Domestic Income (125) _________ International Magnum (135) _________
| Emerging Growth (126) _________ Mid Cap Value (136) _________
| Emerging Markets Equity (127) _________ Money Market (137) _________
| Enterprise (128) _________ Xxxxxx Xxxxxxx
| Equity Growth (132) _________ Real Estate
| Fixed Income (129) _________ Securities (138) _________
| Global Equity (130) _________ Strategic Stock (141) _________
| Government (131) _________ Value (139) _________
| Growth and Income (133) _________ Other _____________________________
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[ ] AUTOMATIC 7.| [ ] Add [ ] Stop Automatic Rebalancing
REBALANCING | [ ] Change Automatic Rebalancing of variable investments to the percentage allocations indicated below:
| [ ] Quarterly [ ] Semiannually [ ] Annually (based on certificate anniversary)
($25,000 MINIMUM) | Asian Equity (140) ________% High Yield (134) ________%
USE WHOLE PERCENTAGES; | Domestic Income (125) ________% International Magnum (135) ________%
TOTAL MUST EQUAL 100%. | Emerging Growth (126) ________% Mid Cap Value (136) ________%
| Emerging Markets Equity (127) ________% Money Market (137) ________%
| Enterprise (128) ________% Xxxxxx Xxxxxxx
| Equity Growth (132) ________% Real Estate
| Fixed Income (129) ________% Securities (138) ________%
| Global Equity (130) ________% Strategic Stock (141) ________%
| Government (131) ________% Value (139) ________%
| Growth and Income (133) ________% Other _____________________________
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[ ] CHANGE ALLOCATION 8.| Asian Equity (140) ________% High Yield (134) ________%
OF FUTURE PURCHASE | Domestic Income (125) ________% International Magnum (135) ________%
PAYMENTS | Emerging Growth (126) ________% Mid Cap Value (136) ________%
| Emerging Markets Equity (127) ________% Money Market (137) ________%
USE WHOLE PERCENTAGES; | Enterprise (128) ________% Xxxxxx Xxxxxxx
TOTAL MUST EQUAL 100%. | Equity Growth (132) ________% Real Estate
| Fixed Income (129) ________% Securities (138) ________%
| Global Equity (130) ________% Strategic Stock (141) ________%
| Government (131) ________% Value (139) ________%
| Growth and Income (133) ________% Other _____________________________
|
| NOTE: A change to the allocation of future purchase payments will not alter Automatic Rebalancing
allocations.
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[ ] TRANSFER OF 9.| Indicate division number along with gross dollar or percentage amount. (Maintain $ or % consistency)
ACCUMULATED |
VALUES | % or $_______ from Div.______ to Div.______ % or $________ from Div. ________ to Div. _______
|
| % or $_______ from Div.______ to Div.______ % or $________ from Div. ________ to Div. _______
|
| % or $_______ from Div.______ to Div.______ % or $________ from Div. ________ to Div. _____
|
| % or $_______ from Div.______ to Div.______ % or $________ from Div. ________ to Div. _______
|
| NOTE: If a tranfer is elected and Automatic Rebalancing is active on your account, you may to consider
| changing the Automatic Rebalancing allocations (Section 7). Otherwise, the Automatic Rebalancing
| will transfer funds in accordance with instructions on file.
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[ ] SYSTEMATIC 10.| Specified Dollar Amount $___________________________
WITHDRAWAL |
| Frequency: [ ] Monthly [ ] Quarterly [ ] Semiannually [ ] Annually
(ALSO COMPLETE |
SECTIONS 13 & 14.) | To begin on _________/_______/_________ (Date must be between the 5th and 24th of the month and at
| MM DD YY least 30 days after issue date.)
($100 MINIMUM | Unless specified below, withdrawals will be taken from the divisions as they are currently allocated
WITHDRAWAL) | in your certificate.
|
PERCENTAGES (WHOLE % | $ or %_______ Div. No.______ $ or %_______ Div. No. ______ $ or %_______ Div. No. ______
ONLY)MUST EQUAL 100%, |
OR DOLLARS MUST EQUAL | $ or %_______ Div. No.______ $ or %_______ Div. No. ______ $ or %_______ Div. No. ______
TOTAL AMOUNT. |
| $ or %_______ Div. No.______ $ or %_______ Div. No. ______ $ or %_______ Div. No. ______
|
| NOTE: The systematic withdrawal option terminates on the certificate's annuity date. You may cancel the
| systematic withdrawal process at any time by notifying AGNY in writing.
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[ ] REQUEST FOR 11.| Amount requested is to be ( ) net OR ( ) gross of applicable charges Total Amount=$___________
PARTIAL |
WITHDRAWAL | $ or %_______ Div. No.______ $ or %_______ Div. No. ______ $ or %_______ Div. No. ______
|
| $ or %_______ Div. No.______ $ or %_______ Div. No. ______ $ or %_______ Div. No. ______
(ALSO COMPLETE |
SECTIONS 13 & 14.) | $ or %_______ Div. No.______ $ or %_______ Div. No. ______ $ or %_______ Div. No. ______
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[ ] REQUEST FOR 12.| [ ] Certificate attached
FULL SURRENDER | [ ] I hereby declare that the certificate specified has been lost, detroyed, or mislaid and request
| that the value of the certificate be paid. I agree to indemnify and hold harmless AGNY against any
(ALSO COMPLETE | claims which may be asserted on my behalf and on the behalf of my heirs, assignees, legal
SECTIONS 13 & 14.) | representatives, or any other person claiming rights derived through me against AGNY on the basis
| of the certificate.
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[ ] METHOD OF 13.| NOTE: If no method is indicated, check(s) will be mailed to the owner of the address of record.
DISTRIBUTION | Check one: [ ] Mail check to owner. [ ] Mail check to alternate address. [ ] Deposit funds directly
| to bank/firm.*
| (available only for
| systematic withdrawals)
| _______________________________________________________________________________________________________
| INDIVIDUAL OR BANK/FIRM
|
| ________________________________________________________ ___________________________________________
| ADDRESS CITY/STATE/ZIP
|
| ________________________________________________________ Type of account: [ ] Checking [ ] Savings
| IF BANK/FIRM, PROVIDE ACCOUNT NUMBER TO BE
| REFERENCED FOR DEPOSIT.
| * Enclose a voided check from account where funds are to be deposited.
| PLEASE DO NO ENCLOSE A DEPOSIT SLIP.
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[ ] NOTICE OF 14.| The taxable portion of the distribution you receive from you annuity certificate is subject to federal
WITHHOLDING | income tax withholding unless you elect not to have withholding apply. Withholding of state income tax
| may also be required by your state of residence. You may elect not to have withholding apply by
| checking the appropriate box below. If you elect not to have withholding apply to your distribution or
| if you do not have enough income tax withheld, you may be responsible for payment of estimated tax. You
| may incur penalties under the estimated tax rules if your withholding and estimated tax are not
| sufficient.
| Check one: [ ] I do NOT want income tax withheld from this distribution.
| [ ] I do want 10% or ____________% income tax withheld from this distribution.
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[X] AFFIRMATION/ 15.| CERTIFICATION: Under penalties of perjury, I certify (1) that the number shown on this form is my
SIGNATURE | correct taxpayer identification number and (2) that I am not subject to backup withholding under
| Section 3406(a)(1)(C) of the Internal Revenue Code.
(COMPLETE THIS SECTION |
FOR ALL REQUESTS.) | The Internal Revenue Service does not require your consent to any provision of this document other
| than the certification required to avoid backup withholding.
|
|
| ____________________________________ _______________________________________________________________
| DATE SIGNATURE OF CERTIFICATE OWNER(S)
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