Variable Annuity Withdrawal Request Form

Contract Number Owner(s) Name

Name of Payee(s) If Other Than Owner(s)

Address To Which Check Should Be Sent If Other Than Owner(s)

City State Zip Code

In 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If no source is indicated, the amount withdrawn will be deducted from each portfolio in the proportion that it bears to the total Contract value.

Portfolio Percentage

%

%

%

%

%

This payment discharges the Company from further obligation to pay benefits to the extent the Contract is reduced by this withdrawal.

Federal, state, and local taxes may be payable on a portion or all of the amount paid. Please consult tax and/or legal counsel prior to submitting this request. Charges will be assessed on amounts withdrawn where prescribed by the Contract.

The Owner(s) declare(s) under penalty of perjury that the taxpayer identification number or social security number furnished on this request is correct.

Owner’s Signature Social Security Number Date

Joint 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.

* See Signature guarantee require-ments below.

Select One:

AIG Life Insurance Company AIG SunAmerica Life Assurance Company

American International Life Assurance First SunAmerica Life Insurance Company

Company of New York

All 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, P.O. Box 3031 Berwyn, PA 19312-0031

(800) 255-8402 Fax: (610) 695-8265

VP-0018 4/03

AIG SunAmerica Life Assurance Company

First SunAmerica Life Insurance Company

*Note: A Signature Guarantee is required for any withdrawal request totaling $500,000.00 or more.

Federal Income Tax Withholding Notice and Election

Any taxable portion of the payment you are requesting is subject to Federal income tax withholding. HOWEVER, YOU MAY ELECT NOT TO HAVE WITHHOLDING APPLY.

Please 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 rules.

One 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 Date

Joint Owner’s Signature (if applicable) Social Security Number Date

Lost Contract Statement

Lost 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., 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 due.

Owner’s Signature Social Security Number Date

Joint Owner’s Signature (if applicable) Social Security Number Date

OVAWDREQ0305

Variable Annuity Withdrawal Request Form (continued)

*Note: A Signature Guarantee is required for any withdrawal request totaling $500,000.00 or more.