WithdraWal request/surrender For VoYa rolloVer products

1 Page 1 of 4 - Incomplete without all pages. Order #144325 12/30/2018 TM: PAYOUTSRVS/DISTRIBW ithdraWal request /surrenderFor voya indiVidual annuitY accountsVoya Retirement Insurance and Annuity CompanyVoya Institutional Trust Company, Custodian ( the Company )Members of the voya family of companiesCentral rolloVer /Payout Services DepartmentPO Box 990063, Hartford, CT 06199-0063 Phone: 800-262-3862 Fax: 800-643-8143 Good orderGood order is receipt at our designated location of this form and any other required information or documents that have been accurately and entirely completed, and includes all appropriate signatures in the designated areas.

2 Forms and any other requested information not received in good order as determined by us may be returned to you for correction and processed upon re-submission in good order at our designated and condiTionsYou should consult with your tax advisor prior to taking any distributions to determine applicable premature distribution penalties. We are required to report all disbursements to the Internal Revenue Service (IRS).The undersigned warrants that no insolvency or bankruptcy proceedings are pending against this contract or against any interest of the undersigned therein.

3 It is further acknowledged that our furnishing of this form does not constitute an admission that there is any contract in ( , administrative fees, early WithdraWal , and/or surrender fees) may be applicable. Please refer to the prospectus or call our Customer Service Center for details. When a deferred sales charge is applicable, the free WithdraWal amount will be based upon the account valuation calculation appropriate to your contract, following receipt by Customer Service Center. The amount of this charge will be adjusted for amounts already received and/or for amount(s) requested for distribution during the account year through the election of a Systematic Distribution Option.

4 In the case of partial surrenders, applicable fees will be deducted from the remaining balance of the account, and the check will be for the amount requested less any withholding for federal or state income conTracT/accoUnT oWner informaTionDaytime Phone Home Phone Owner Name (last, first, middle initial) SSN (Required) Plan # E-mail Address SSN/TIN Insured/Annuitant Name (If different than owner.) SSN/TIN Joint Owner Name (If applicable.) 2. sUrrenders (Surrenders may be subject to a deferred sales charge.) Total surrender Partial surrender Amount Available Free of Deferred Sales Charge Percent of Contract Value % Specific Dollar Amount $ Required Minimum Distribution (RMD) Withdraw specified dollar amount $ Calculate RMD Include previous year-end balance if in first year of contract $ Page 2 of 4 - Incomplete without all pages.

5 Order #144325 12/30/2018 TM: PAYOUTSRVS/DISTRIB3. disTribUTion informaTionAmounts will be taken pro rata from each investment option in the same proportion as their respective values have to the total value of the account. If, however, you wish to have your partial surrender from a specific investment option, you may do so by specifying in the space provided here.

6 Percentages indicated must be rounded to the nearest 1%. Details regarding your investments can be obtained from your quarterly investment optionsVariable/fixed investment optionsfund name/numberamount/%fund name/numberamount/%Fixed Account4. reason for disTribUTion (Please choose one. Deferred sales charge may be applied. Please refer to prospectus for details.) Premature Distribution (taxpayer has not reached age 59 ) Normal Distribution (taxpayer is at least age 59 ) Excess Contributions Plus Earnings: IRA Only Please state tax year ( voya will calculate the earnings on excess contributions for non-custodial owned Traditional and Roth IRA s.)

7 Employer Contribution (Only for use with clients in a SEP IRA or in plan #666994) Employee Contribution (Only for use with clients in a SEP IRA or in plan #666994) Direct rolloVer /Transfer (Please complete section 5.) Recharacterization Other (describe) Direct rolloVer to a Non- voya Roth IRA Direct rolloVer /Transfer to a Non- voya Account. The following items must be submitted: A Letter of Acceptance from the recipient institution. An Absolute Assignment from the recipient institution, if the funds are Non-Qualified (1035 Exchange). Direct rolloVer to a voya Traditional IRA Direct rolloVer to a voya Roth IRA Direct rolloVer /Transfer to a voya Qualified Plan: if choosing a direct rolloVer to a voya account, please select destination account(s) below:5.

8 rolloVer /Transfer oPTions 6. PaymenT informaTionPayee SSN Address (#, street, PO Box) City/Town State ZIP Please indicate to whom your distribution should be made payable. If you have chosen a Direct Transfer, rolloVer , 1035 Exchange, please complete and attach a State Replacement form, if applicable. In addition, also include: A Letter of Acceptance from the recipient institution, if the funds are Qualified. An Absolute Assignment from the recipient institution, if the funds are Non-Qualified (1035 Exchange). noTe: For rollovers to a voya account the WithdraWal request will not be processed until the new account application is received.

9 voya express Mutual Fund voya express VA voya express Fixed Annuity voya Renuity voya SPIA voya Select Advantage voya choice IRA voya Select Rate voya Select Opportunities voya Indexed Annuity voya Advisor/Brokerage Account voya Funds voya Premier products Other _____ Page 3 of 4 - Incomplete without all pages. Order #144325 12/30/2018 TM: PAYOUTSRVS/DISTRIB8.

10 If voya has qUesTions reGardinG This WithdraWal request Please Contact: Name Phone E-mail Address 7. eLecTronic fUnd Transfer (Choosing this option will result in more timely access to your funds.)By completing this section, I authorize voya to initiate an electronic funds transfer (EFT). Take advantage of a convenient method to have your distribution electronically deposited into your bank account. The electronic deposit is immediately available for use once the transfer is completed. The Company does not charge you for this service. The payment is typically completed within 3-4 business verify the correct ABA routing number with your bank.