EXHIBIT (5)(b)
AMERICAN GENERAL LIFE INSURANCE COMPANY of New York ("AGNY")
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A Subsidiary of American General Corporation
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Houston, Texas
-SERVICE REQUEST-
GENERATIONS
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Variable Annuity
COMPLETE AND RETURN THIS REQUEST TO:
Xxxxxxx Administration
P.O. Box 1401
Houston, TX 77251-1401
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1. [X] CERTIFICATE INDENTIFICATION (COMPLETE SECTION 1 AND 15 FOR ALL
REQUESTS.) INDICATE CHANGE OR REQUEST DESIRED BELOW.
CERTIFICATE#:_________________________ ANNUITANT:_________________________
CERTIFICATE OWNER(S):_____________________________________________________
(Name and
Address:) ________________________________________________________
[ ] Check here
if change ________________________________________________________
of address
S.S. NO. OR TAX I.D. NO.:____/____/____ Phone Number:( )_______________
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2. [ ] NAME CHANGE
[ ]Annuitant* [ ]Beneficiary* [ ]Owner(s)* (*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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3. [ ] DUPLICATE 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 to AGNY to be
voided.
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4. [ ] BENEFICIARY CHANGE
THIS SECTION IS FOR HOME OFFICE USE ONLY
__________________________________________________________________________
PRIMARY | CONTINGENT
___________________________________|______________________________________
This change of beneficiary has been approved by AGNY, at its Home Office,
and presentation of the Certificate for endorsement has been waived.
DATE OF APPROVAL:_____________
By:___________________________________________________
AMERICAN GENERAL LIFE INSURANCE COMPANY OF NEW YORK
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5. [ ] AUTOMATIC ADDITIONAL PREMIUM PAYMENT OPTION
_________ By initialing here, I authorize American General Life of New
York to collect $________________ (Min. $100) starting month/day
__________ by initiating electronic debit entries against my bank account
with the following frequency:
[ ]Monthly [ ]Quarterly [ ]Semiannually [ ]Annually
(Attach voided check to Service Request)
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6. [ ] DOLLAR COST AVERAGING
Dollar-cost average [ ] $______ OR [ ] ______% (whole % only)
Begin Date:__/__/__
Taken from [ ] (137) Money Market OR [ ] (142) 1-Year Fixed Account
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)
[(140) Asian Equity ____% (129) Fixed Income ____% (136) Mid Cap Value ____%
(125) Domestic Income ____% (130) Global Equity ____% (137) Money Market ____%
(126) Emerging Growth ____% (131) Government ____% (138) Real Estate Securities ____%
(127) Emerging Markets Equity ____% (133) Growth and Income ____% (139) Value ____%
(128) Enterprise ____% (134) High Yield ____% Other________________ ____%]
(132) Equity Growth ____% (135) International Magnum ____%
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7. [ ] AUTOMATIC REBALANCING
($25,000 MINIMUM)
Use whole percentages. Total must equal 100%
[ ]ADD [ ]CHANGE automatic rebalancing of variable investments to the
percentage allocations indicated below:
[ ]Quarterly [ ]Semiannually [ ]Annually (Based on certificate anniversary)
[(140) Asian Equity ____% (129) Fixed Income ____% (136) Mid Cap Value ____%
(125) Domestic Income ____% (130) Global Equity ____% (137) Money Market ____%
(126) Emerging Growth ____% (131) Government ____% (138) Real Estate Securities ____%
(127) Emerging Markets Equity ____% (133) Growth and Income ____% (139) Value ____%
(128) Enterprise ____% (134) High Yield ____% Other________________ ____%]
(132) Equity Growth ____% (135) International Magnum ____%
[ ]STOP automatic rebalancing
NOTE: Automatic rebalancing is only available for variable divisions.
Automatic Rebalancing will not change allocation of future purchase
payments.
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8. [ ] CHANGE ALLOCATION OF FUTURE PURCHASE PAYMENTS
Use whole percentages. Total must equal 100%
[(140) Asian Equity ____% (129) Fixed Income ____% (136) Mid Cap Value ____%
(125) Domestic Income ____% (130) Global Equity ____% (137) Money Market ____%
(126) Emerging Growth ____% (131) Government ____% (138) Real Estate Securities ____%
(127) Emerging Markets Equity ____% (133) Growth and Income ____% (139) Value ____%
(128) Enterprise ____% (134) High Yield ____% Other________________ ____%
(132) Equity Growth ____% (135) International Magnum ____% (142) 1 Year Fixed Account ____%]
NOTE: A change to the allocation of future purchase payments, will not
alter Automatic Rebalancing allocations.
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AGNY 8794-1
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9. [ ] TRANSFER OF ACCUMULATED VALUES
Indicate division number along with gross dollar or percentage amount.
(Maintain $ or % consistency)
% 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 transfer is elected and Automatic Rebalancing is active on your
account, you may want 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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10. [ ] SYSTEMATIC WITHDRAWAL
(ALSO COMPLETE SEC. 14)
($100 minimum withdrawal)
Percentages (whole % only)
must equal 100%, or
Dollars must equal total amount.
Specified Dollar Amount $______________________
Frequency: [ ]Monthly [ ]Quarterly [ ]Semiannually [ ]Annually
To Begin on___/___/___
(Date must be between the 5th and 24th of the month and at least 30 days
after issue date.)
Unless specified below, withdrawals will be taken from the divisions as
they are currently allocated in your certificate.
$ or %________ Xxx.Xx.________ $ or %________ Xxx.Xx.________ $ or %________ Xxx.Xx.________
$ or %________ Xxx.Xx.________ $ or %________ Xxx.Xx.________ $ or %________ Xxx.Xx.________
$ or %________ Xxx.Xx.________ $ or %________ Xxx.Xx.________ $ or %________ Xxx.Xx.________
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11. [ ] REQUEST FOR PARTIAL WITHDRAWAL (ALSO COMPLETE SEC. 14)
Amount requested is to be ( ) net OR ( ) gross of applicable charges.
Total Amount=$________
$ or %________ Xxx.Xx.________ $ or %________ Xxx.Xx.________ $ or %________ Xxx.Xx.________
$ or %________ Xxx.Xx.________ $ or %________ Xxx.Xx.________ $ or %________ Xxx.Xx.________
$ or %________ Xxx.Xx.________ $ or %________ Xxx.Xx.________ $ or %________ Xxx.Xx.________
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12. [ ] REQUEST FOR FULL SURRENDER (ALSO COMPLETE SEC. 14)
[ ] Certificate attached
[ ] I hereby declare that the certificate specified above has been lost,
destroyed, or mislaid and request that the value of the certificate be
paid. I agree to indemnify and hold harmless AGNY against any claims which
may be asserted on my behalf and on the behalf of my heirs, assignees,
legal representatives, or any other person claiming rights derived through
me against AGNY on the basis of the certificate.
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13. [ ] ALTERNATE PAYEE
Check(s) will be made payable to the Certificate Owner(s) and mailed to
the Owner's address of record unless specified otherwise below:
___________________________________________
Name of Individual or Financial Institution
______________________________
Account Number (if applicable)
_________________________________________________________________________
Address City State Zip
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14. [ ] NOTICE OF WITHHOLDING
The taxable portion of the distribution you receive from your annuity
certificate is subject to federal 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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15. [X] AFFIRMATION/SIGNATURE
(COMPLETE THIS SECTION FOR ALL REQUESTS.)
CERTIFICATION: Under penalty of perjury, I certify (1) that the number
shown on this form is my 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
The Internal Revenue Service does not require your consent to any
provision of this document other than the certifications required to avoid
backup withholding.
_________________ _____________________________________
DATE SIGNATURE OF OWNER(S)
AGNY 8794-1
