Annuities

New York Life Insurance and Annuity Corporation
Fixed Deferred Annuity Client Profile and Policy Disclosure Form

|Owner Information|

| |Date of Birth| |
|Owner Name (First, M.I., Last) |Month |Day |Year |SS # or Tax ID #|
| | | | | |

|Annual GrossIncome: | |Net Worth*: | |Current Tax Bracket: |
|(Include Spousal Income) ||(Include spousal assets) | |0 – 15% |
| | || |16 – 28% |
|$ | |$ | |Over 28%|

*Net worth excludes value of primary residence, furnishings, automobile(s), and face amounts of life insurance policies. (Note: The cash value of any life insurancepolicies should be included in the net worth calculation.)

|Joint Owner Information|

| |Date of Birth | |...