Document:

RELIASTAR LIFE INSURANCE COMPANY OF NEW YORK

                                      ROTH

                       INDIVIDUAL RETIREMENT ANNUITY RIDER

The following language amends and takes precedence over contrary language in the
Contract to which it is attached.

All references in this rider to:
    IRC or Code means the Internal Revenue Code of 1986 as amended and all rules
        and regulations thereunder.
    Contract means the policy or contract to which this rider is attached.
    Owner means the person ("insured" or "annuitant") covered by the contract.

1.   This Contract may not be transferred, sold, assigned, discounted or pledged
     as collateral:

     (a)  for a loan;

     (b)  as security for the performance of an obligation; or

     (c)  for any other purpose;

     (d)  to any person other than to us under surrender or settlement.

2.   The premiums applicable to this Contract will be applied to accumulate a
     retirement saving fund for the annuitant/Owner.

3.  All contributions shall be in cash and, except in the case of a
    trustee-to-trustee transfer from another Roth IRA, or in the case of a
    qualified rollover contribution, may not exceed the excess of the Owner's
    contribution limit for the taxable year over the aggregate contributions
    made during the taxable year to all other Roth IRA's and IRA's held by the
    Owner. Contributions may be made without respect to the age of the Owner

    The contribution limit for the taxable year is either (1) the lesser of
    $2,000 or 100% of compensation of the Owner for the taxable year, or (2)
    where the Owner files a joint return and receives less compensation for the
    taxable year than the Owner's spouse, the lesser of $2,000 or 100% of
    compensation of the Owner and the Owner's spouse for the taxable year less
    the spouse's contribution to the Roth IRA or IRA for the taxable year (if
    any).

    When the Owner's adjusted gross income (AGI) exceeds the applicable dollar
    limit (ADL; see description below), the annual contribution limit is reduced
    by the following amount:

      Annual Contribution Limit  x   Owner's AGI - ADL
                                     ------------------------------------
                                     $15,000 ($10,000 if Owner is Married)

    For the purposes of this section, AGI does not include any amount included
    in gross income as a result of a rollover of an IRA or a Roth IRA and is
    reduced by any deduction under Section 219 of the Code.

    The ADL is $150,000 for an Owner filing a joint return, $95,000 for an Owner
    filing a single return, and $0 for a married Owner filing a separate return.

4.   A qualified rollover contribution described in 408A(e) can be made only
     from (1) another Roth IRA or (2) another IRA, which is not a Roth IRA, and
     can be made from an IRA other than a Roth IRA only if the Owner's adjusted
     gross income for the taxable year of the rollover does not exceed $100,000.

FG-RA-1038-05/98

<PAGE>

5.  All distributions made under this Contract, after the Owner's death, shall
    be made in accordance with the requirements of IRC Section 401(a)(9)
    including any regulations under that Section. The above Section and
    regulations are incorporated by reference.

6.  No provision of this Contract or any supplementary contract issued upon the
    death of the Owner in exchange for this Contract will apply where it permits
    or provides for settlement of such amount in any manner other than a
    complete distribution of the Owner's entire interest by December 31 of the
    calendar year containing the fifth anniversary of the Owner's death, except
    to the extent that:

    (a)  If the Owner's interest is payable to a designated beneficiary, then
         the entire interest of the Owner may be distributed over the life of
         such beneficiary, or over a period not extending beyond the life
         expectancy of such designated beneficiary, provided that distributions
         start by December 31st of the year following the year of the Owner's
         death. If the beneficiary is the Owner's surviving spouse, distribution
         is not required to begin before December 31st of the year in which the
         Owner would have turned 70 1/2.

    (b)  If the designated beneficiary is the Owner's surviving spouse, the
         spouse may treat the Contract as his or her own Roth individual
         retirement arrangement (IRA). This election will be deemed to have been
         made if the spouse:

          (i)   makes a regular Roth IRA contribution to the Contract;

          (ii)  makes a rollover to or from such Contract;

          (iii) fails to elect either of the provisions in Sections 6 or 6(a)
                above.

7.   Life expectancy is computed by use of the expected return multiples in
     Section 1.72-9 of the Treasury Regulations. For purposes of distributions
     beginning after the Owner's death, unless otherwise elected by the
     surviving spouse by the time distributions are required to begin, life
     expectancies shall be recalculated annually. An election not to recalculate
     shall be irrevocable by the surviving spouse and shall apply to all
     subsequent years.

     The life expectancy of a non-spouse beneficiary shall be calculated using
     the attained age of such beneficiary during the calendar year in which
     distributions are required to begin pursuant to this section, and payments
     for any subsequent calendar year shall be calculated based on such life
     expectancy reduced by one for each calendar year which has elapsed since
     the calendar year life expectancy was first calculated.

8.   This Contract will be for the exclusive benefit of the Owner or his or her
     beneficiary. The entire interest of the Owner in this Contract will be
     nonforfeitable.

9.   We will furnish annual calendar year reports concerning the status of this
     Contract, including information related to any distribution from the
     Contract.

10.  We may amend this Contract to conform to the provisions of the IRC,
     Internal Revenue Regulations or published Internal Revenue Rulings.

      President  /S/ Chris Schreier        Secretary  /S/ Paula Cludray-Engelke

FG-RA-1038-05/98FIRST GOLDEN AMERICAN                                      FLEXIBLE PREMIUM
LIFE INSURANCE COMPANY OF NEW YORK            DEFERRED COMBINATION VARIABLE
                                              AND FIXED ANNUITY APPLICATION

FIRST GOLDEN AMERICAN LIFE INSURANCE COMPANY OF NEW YORK IS A STOCK
  COMPANY DOMICILED IN NEW YORK, NEW YORK

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1.   OWNER(S)
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Name                     Male      Female    Soc. Sec. # or Tax ID.#
                         / /        / /
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Permanent Address        Phone (   )

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City                     State     Zip       Date of Birth

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2.   ANNUITANT (IF OTHER THAN OWNER)
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Name                     Male      Female    Soc. Sec. # or Tax ID.#
                         / /        / /
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Permanent Address        Phone (   )

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City                     State     Zip       Date of Birth  Relation
                                                            to Owner
===========================================================================
     CONTINGENT ANNUITANT (OPTIONAL)
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Name                               Address                  Relation
                                                            to Owner
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3.   PRIMARY BENEFICIARY(IES)      (IF MORE THAN ONE - INDICATE %)
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Name(s)                                                     Relation
                                                            to Owner
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   CONTINGENT BENEFICIARY(IES)     Name                     Relation
                                                            to Owner
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4.   PLAN
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     / / DVA PLUS
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5.   DEATH BENEFIT OPTIONS
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     / / Annual Ratchet           / / Standard
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6.   INITIAL PREMIUM AND ALLOCATION INFORMATION
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     (A)  INITIAL PREMIUM PAID $__________ MAKE CHECK PAYABLE TO FIRST
          GOLDEN AMERICAN LIFE INSURANCE COMPANY OF NEW YORK
          Fill in percentages for premium allocation below (see INITIAL)
     (B)  CHARGE DEDUCTION DIVISION: Optional. Please check box to elect.
          / /

<Table>
<Caption>

     ACCOUNT DIVISION                  INVESTMENT ADVISER                 (A) INITIAL
<S>                                <C>                                    <C>

RESEARCH                           MASSACHUSETTS FINANCIAL SERVICES                 %
                                      COMPANY (MFS)
MID-CAP GROWTH                     MASSACHUSETTS FINANCIAL SERVICES                 %
                                      COMPANY (MFS)
TOTAL RETURN                       MASSACHUSETTS FINANCIAL SERVICES                 %
                                      COMPANY (MFS)
SMALL CAP                          FRED ALGER MANAGEMENT, INC.                      %
GROWTH & INCOME                    ALLIANCE CAPITAL MANAGEMENT L.P.                 %
GROWTH                             JANUS CAPITAL CORPORATION                        %
FULLY MANAGED                      T. ROWE PRICE ASSOCIATES INC.                    %
STRATEGIC EQUITY                   AIM CAPITAL MANAGEMENT, INC.                     %
EQUITY INCOME                      T. ROWE PRICE ASSOCIATES INC.                    %
RISING DIVIDENDS                   KAYNE, ANDERSON INV. MGMT., L.P.                 %
CAPITAL APPRECIATION               AIM CAPITAL MANAGEMENT, INC.                     %
VAlUE EQUITY                       EAGLE ASSET MANAGEMENT, INC.                     %
MANAGED GLOBAL                     PUTNAM INVESTMENT MANAGEMENT, INC.               %
EMERGING MARKETS                   PUTNAM INVESTMENT MANAGEMENT, INC.               %
HARD ASSETS                        BARING INTERNATIONAL INVESTMENT LIMITED          %
REAL ESTATE                        EII REALTY SECURITIES, INC.                      %
LIMITED MATURITY BOND              ING INVESTMENT MANAGEMENT, LLC                   %
LIQUID ASSET                       ING INVESTMENT MANAGEMENT, LLC                   %
GLOBAL FIXED INCOME                BARING INTERNATIONAL INVESTMENT LIMITED          %
DEVELOPING WORLD                   BARING INTERNATIONAL INVESTMENT LIMITED          %

FIXED ALLOCATION ELECTION           1-YEAR                                          %
FIXED ALLOCATION ELECTION           3-YEAR                                          %
FIXED ALLOCATION ELECTION           5-YEAR                                          %
FIXED ALLOCATION ELECTION           7-YEAR                                          %
FIXED ALLOCATION ELECTION          10-YEAR                                          %

                                        TOTAL                                    100%
</Table>

First Golden American Life Insurance Company of New York, Variable Products
Service Center, P.O. Box 11520, Church Street Station, New York, NY 10286-1520

                             1-800-963-9539
FG-AA-1000-12/95

<Page>

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7.   OPTIONAL SYSTEMATIC PARTIAL WITHDRAWALS
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     If you want to receive Systematic Partial Withdrawals, your request
     must be received in writing. For the appropriate form, please call our
     Customer Service Center: 1-800-366-0066.
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8.   TAX-QUALIFIED PLANS  If you are funding a qualified plan, please
          specify type.
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     / / IRA     / / IRA Rollover     / / SEP/IRA
     / / Other  ________________________
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9.   REPLACEMENT
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     Will the coverage applied for replace any existing annuity or life
     insurance policies on the annuitant's life?

     / / Yes (If yes, please complete following)      / / No
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Company Name                             Policy Number       Face Amount
---------------------------------------------------------------------------

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10.  READ THE FOLLOWING STATEMENTS CAREFULLY AND SIGN BELOW:

     - BY SIGNING BELOW, I ACKNOWLEDGE RECEIPT OF THE PROSPECTUS. I
     UNDERSTAND THAT THIS CONTRACT'S CASH SURRENDER VALUE, 1) WHEN BASED ON
     THE INVESTMENT EXPERIENCE OF A SEPARATE ACCOUNT DIVISION, MAY INCREASE
     OR DECREASE ON ANY DAY AND THAT NO MINIMUM VALUE IS GUARANTEED, AND 2)
     WHEN, BASED ON THE FIXED ACCOUNT, MAY BE SUBJECT TO A MARKET VALUE
     ADJUSTMENT, THE OPERATION OF WHICH MAY CAUSE THE VALUES TO INCREASE OR
     DECREASE.  THIS CONTRACT IS IN ACCORD WITH MY ANTICIPATED FINANCIAL
     NEEDS.

     - I AGREE THAT, TO THE BEST OF MY KNOWLEDGE AND BELIEF, ALL STATEMENTS
     AND ANSWERS IN THIS APPLICATION ARE COMPLETE AND TRUE AND MAY BE RELIED
     UPON IN DETERMINING WHETHER TO ISSUE THE CONTRACT. MY ANSWERS WILL FORM
     A PART OF ANY CONTRACT TO BE ISSUED, AND ONLY THE OWNER AND FIRST
     GOLDEN AMERICAN HAVE THE AUTHORITY TO MODIFY THIS APPLICATION.

     - CONTRACTS AND POLICIES AND UNDERLYING SERIES SHARES OR SECURITIES
     WHICH FUND CONTRACTS AND POLICIES ARE NOT INSURED BY THE FDIC OR ANY
     OTHER AGENCY. THEY ARE NOT DEPOSITS OR OTHER OBLIGATIONS OF ANY BANK
     AND ARE NOT BANK GUARANTEED. ALSO, THEY ARE SUBJECT TO MARKET
     FLUCTUATION, INVESTMENT RISK AND POSSIBLE LOSS OF PRINCIPAL INVESTED.

______________________________________      _____________________________
Signature of Owner                          Signed at (City, State)  Date

______________________________________      _____________________________
Signature of Joint Owner (if applicable)    Signed at (City, State)  Date

______________________________________      _____________________________
Signature of Annuitant (if other than       Signed at (City, State)  Date
                         owner)

Client Account No. (if applicable)_____________________
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FOR AGENT USE ONLY
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DO YOU HAVE REASON TO BELIEVE THAT THE COVERAGE APPLIED FOR WILL REPLACE
ANY EXISTING ANNUITY OR LIFE INSURANCE ON THE ANNUITANT'S LIFE?
       / / YES       / / NO

__________________________   ________________________   ___________________
Agent Signature              Print Agent Name & No.     Social Security No.

__________________________________
Broker/Dealer/Branch
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Amendment to Application
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First Golden American Life Insurance Company of New York, Variable Products
Service Center, P.O. Box 11520, Church Street Station, New York, NY 10286-1520

                             1-800-963-9539

FG-AA-1000-12/95

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