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Annuity Withdrawal / Surrender Request

Page 1 of 5 AGLC108865 Rev1219 American General Life Insurance Company The United States Life Insurance Company in the City of New YorkA member of American International Group, Inc. (AIG)In this form, the Company refers to the insurance company whose name is checked above. The Company shown above is solely responsible for the obligation and payment of benefits under any policy that it may issue. No other Company is responsible for such obligations or Instructions: Send form(s) to: Standard Address PO Box 305355 Nashville, TN 37230-5355 Fax: 1-844-930-0370 Variable Life Service Center PO Box 305600 Nashville, TN 37230-5600 Fax: 713-620-6653 SECTION A - EXISTING POLICY INFORMATIONP lease fill out all applicable info

losses associated with the withdrawal or loan, including costs of recovery and reasonable attorney fees. You and the Internal Revenue Service will be provided with an informational tax form after the close of the calendar year. A withdrawal of any type, before age 59½, may subject you to an IRS penalty tax. ...

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