Variable Annuity Withdrawal Request Form - PRIME

1 Variable Annuity Withdrawal Request FormContract Number Owner(s) NameName of Payee(s) If Other Than Owner(s)Address To Which Check Should Be Sent If Other Than Owner(s)City State Zip CodeIn accordance with the terms of this Contract, the following action is authorized: Total Withdrawal The Contract must be submitted or the Lost Contract Statement, on the reverse side, completed. Partial Withdrawal As requested below: Select Only One: $_____ _____% of Contract Value Maximum Free Withdrawal Indicate Source of Payment (Use Whole Percentages Only)If no source is indicated, the amount withdrawn will be deducted from each portfolio in the proportion that it bears to the total Contract Percentage % % % % %This payment discharges the Company from further obligation to pay benefits to the extent the Contract is reduced by this , state, and local taxes may be payable on a portion or all of the amount paid.

2 Please consult tax and/or legal counsel prior to submitting this Request . Charges will be assessed on amounts withdrawn where prescribed by the Owner(s) declare(s) under penalty of perjury that the taxpayer identification number or social security number furnished on this Request is s Signature Social Security Number DateJoint Owner s Signature (if applicable) Social Security Number Date (Continued on Reverse Side)Instructions Both sides must be completed with original signature(s) of the Owner(s). For a total Withdrawal , please return your Contract, including the Schedule page, with this Request . If the Contract cannot be located, please complete the Lost Contract Statement on the reverse side of this Form.

3 * See Signature guarantee require-ments One: AIG Life Insurance Company AIG SunAmerica Life Assurance Company American International Life Assurance First SunAmerica Life Insurance Company Company of New YorkAll companies referenced above collectively referred to as the Company. American International Life Assurance Company of New York AIG Life Insurance Company c/o Delaware Valley Financial Services, Inc. 300 Berwyn Park, Box 3031 Berwyn, PA 19312-0031 (800) 255-8402 Fax: (610) 695-8265VP-0018 4/03 AIG SunAmerica Life Assurance Company First SunAmerica Life Insurance Company*Note: A Signature Guarantee is required for any Withdrawal Request totaling $500, or more. Federal Income Tax Withholding Notice and ElectionAny taxable portion of the payment you are requesting is subject to Federal income tax withholding.

4 HOWEVER, YOU MAY ELECT NOT TO HAVE WITHHOLDING indicate below whether you want Federal income tax withheld from your Withdrawal . Even if you elect not to have Federal income tax withheld, you are liable for payment of Federal income tax on the taxable portion of your Withdrawal and we are obligated to report this information both to you and the Internal Revenue Service. If your payments of estimated tax and withholding, if any, are not adequate, you may also be subject to tax penalties under the estimated tax payment Box Must Be Checked: No Do not withhold Federal income Yes Withhold 10% Federal income tax from any tax from the Withdrawal . taxable portion of the Withdrawal . Owner s Signature Social Security Number DateJoint Owner s Signature (if applicable) Social Security Number DateLost Contract StatementLost statement and undertaking if original Contract is found:In consideration of American International Life Assurance Company of New York/AIG Life Insurance Company, Anchor National Life Insurance Company, First SunAmerica and their Administrator, Delaware Valley Financial Services, Inc.

5 , taking the action requested, the undersigned(s), of lawful age, do(es) hereby certify that the above described Contract has been lost or destroyed and has not been delivered to any person or business enterprise for any right, title or interest in it. I/we agree that if the original Contract should ever come into my/our hands, custody or power, it will be immediately surrendered and no consideration shall be s Signature Social Security Number DateJoint Owner s Signature (if applicable) Social Security Number DateOVAWDREQ0305 Variable Annuity Withdrawal Request Form (continued)*Note: A Signature Guarantee is required for any Withdrawal Request totaling $500, or more.