Document:

EX-(40.(c)

 THE UNITED STATES LIFE INSURANCE COMPANY IN THE CITY OF NEW YORK 

[OPTIONAL]

GUARANTEED LIVING BENEFIT ENDORSEMENT 
 Notwithstanding any provision in the Contract or to the contrary,
this Endorsement becomes a part of the Contract to which it is attached. Should any provision in this Endorsement conflict with the Contract, the provisions of this Endorsement will prevail. 

Subject to the terms and conditions set forth herein this [optional]

Guaranteed Living Benefit Endorsement provides for guaranteed income over the lifetime of the Covered Person(s). You may take Withdrawals under the Guaranteed Living Benefit as prescribed by this Endorsement while
this Endorsement is in effect. 
 ENDORSEMENT DATA PAGE 
  

			
	 COVERED PERSON(S):
	  	 [John Doe
 Jane
Doe]

		
	 ENDORSEMENT EFFECTIVE DATE:
	  	 [May 2, 2016]

		
	 PURCHASE PAYMENT DOLLAR LIMIT:
	  	 The sum of all Purchase Payments cannot exceed [$1,000,000]

 without prior Company approval.

		
	 PURCHASE PAYMENT RESTRICTION:
	  	 Purchase Payments received on or after the [[first] [Contract Anniversary]] will not be accepted into the Contract.

		
	 [INVESTMENT REQUIREMENTS:
	  	 Every Purchase Payment and Spousal Beneficiary Continuation contribution, if any, must be allocated by You in accordance
with the investment options approved by Us, which includes a mandatory allocation of every Purchase Payment and Spousal Beneficiary Continuation contribution, if any, to the Secure Value Account, as shown below. We will notify You of any change to
the permitted investment options.]

		
	 [SECURE VALUE ACCOUNT ALLOCATION:
	  	 [10%] of Purchase Payment(s) and Spousal Beneficiary Continuation contribution, if applicable]

		
	 FREQUENCY AND DATES OF INCOME

BASE STEP-UPS:
	  	 [Quarterly,] [on the Benefit [Quarter] Anniversary]

 ENDORSEMENT FEE: 

The Endorsement Fee is assessed against the [Income Base]

 and deducted from the portion of the Contract Value allocated to the Variable Portfolio(s) or Subaccount(s) at the end of each Benefit [Quarter]

 [starting [1]

 Benefit [Quarter(s)]

 following the Endorsement Effective Date]

. The [Initial]

 Annual Fee Rate is guaranteed not to change for the [first]

 Benefit [Year]

. After the [first] Benefit [Year]

, on each Benefit [Quarter Anniversary]

, we will (1) deduct the fee in effect for the previous Benefit [Quarter]

; and (2) determine the fee rate applicable to the next Benefit [Quarter]

.. The fee rate can increase or decrease each Benefit [Quarter]

, subject to the minimums and maximums in the table below: 
 

 

									
	
Number of Covered
 Persons
on
 Endorsement

Effective Date
	  	
[Initial]

 Annual Fee

Rate
	  	
Minimum Annual
 Fee
Rate
	  	
Maximum Annual
 Fee
Rate
	  	
Maximum Annualized

Fee Rate Increase or
Decrease Each Benefit
[Quarter]*

	One Covered Person	  	[1.10%]	  	[0.60%]	  	[2.20%]	  	+/- [0.25%]
	Two Covered Persons	  	[1.35%]	  	[0.60%]	  	[2.70%]	  	+/- [0.25%]

 *The fee rate can increase or decrease no more than [0.0625%]

 each [quarter]

 [(0.25%/4)]

.. 

  

					
	 USLE-8043 (4/16)
	  	1	  	

 

 
 MAXIMUM ANNUAL WITHDRAWAL AND PROTECTED INCOME PAYMENT PERCENTAGES: 

10 [If no Withdrawals are taken in the first 10 [5] 10 [Benefit] Year(s) or the 10 [Age] at the first Withdrawal of the Covered Person(s) is 10 [[70] or
older], the following table will always be used to determine the Maximum Annual Withdrawal and Protected Income Payment Percentages:] Covered Person(s) Age   at First Withdrawal Maximum Annual Withdrawal Percentage Protected
Income Payment Percentage 12 (One Covered     Person) (Two Covered     Persons) 12 [(One or Two Covered Person(s))]    
If the Income Base is increased on or after Age [65] (One or Two Covered Person(s)) 11 [Less than Age 65]     [5.5%] [5.0%] [3.0%] 11 [4.0%] 11 [Age 65 or
older]     [6.0%] [5.5%] [4.0%] 11 [4.0%] If Withdrawals are taken in the first 10 [5] 10 [Benefit] Year(s) and the 10 [Age] at the first Withdrawal of the Covered Person(s) is 10 [less than Age [70]], the following table will
always be used to determine the Maximum Annual Withdrawal and Protected Income Payment Percentages: Covered Person(s) Age   at First Withdrawal Maximum Annual Withdrawal Percentage Protected Income Payment Percentage 12
(One Covered     Person) 11 (Two Covered     Persons) 11 12 [(One or Two Covered Person(s))]     11
If the Income Base is increased on or after Age [65] (One or Two Covered Person(s)) 11 [Less than Age 65]     [5.0%] [4.5%] [2.5%] 11 [3.5%] 11 [Age 65 or older] [5.5%] [5.0%]
[3.5%] 11 [3.5%] 13 [INCOME BASE MAXIMUM: The Income Base can be no greater than [200%] of the [Purchase Payments] [reduced [proportionately] for [Excess] Withdrawals].] EARLIEST CANCELLATION DATE OF THE GUARANTEED LIVING BENEFIT: The [10th] Benefit
Year Anniversary following the Endorsement Effective Date BENEFIT WITHDRAWAL CHARGE: You may incur a Benefit Withdrawal Charge if You take a partial Withdrawal that exceeds the Maximum Annual Withdrawal Amount or a total Withdrawal of all Your
Contract Value before the end of the [10th] Benefit Year Anniversary following the Endorsement Effective Date. The Benefit Withdrawal Charge is assessed against the [amount in excess of the Maximum Annual Withdrawal Amount] and deducted from: 1. The
partial Withdrawal amount on the date a Withdrawal in excess of the Maximum Annual Withdrawal Amount is taken; and 2. The [Contract Value] upon a total Withdrawal of all Your Contract Value. The Benefit Withdrawal Charge is shown below. NUMBER OF
FULL BENEFIT YEARS ELAPSED SINCE ENDORSEMENT EFFECTIVE DATE BENEFIT WITHDRAWAL     CHARGE* 0 9.00% 1 8.50% 2 7.50% 3 6.50% 4 5.50% 5 4.50% 6 3.50% 7 2.50% 8 1.50% 9 0.50% 10+ 0% *Assessed as a percentage of the Withdrawal
amount in excess of Maximum Annual Withdrawal Amount upon a partial Withdrawal or the Contract Value in excess of Maximum Annual Withdrawal Amount, upon a total Withdrawal of all Your Contract Value. 

  

					
	 USLE-8043 (4/16)
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 [PAYMENTS IN CONNECTION WITH DISTRIBUTION OF THE CONTRACT 

This provision applies only to the Contract to which this Endorsement is attached. If Withdrawal(s) taken to cover payments to the Agent
in connection with advisory or investment management services (Advisory Fee) are greater than the Maximum Annual Withdrawal Amount in any given Benefit Year, no portion of Advisory Fee payments [up to [1.0%] of the Contract Value associated with the
Contract in which this Endorsement is attached to] will be treated as an Excess Withdrawal provided You enroll in the Systematic Withdrawal Program for Advisory Fees. However, any portion of a Withdrawal in a Benefit Year that is greater than the
Maximum Annual Withdrawal Amount (or Required Minimum Distribution as described below in this Endorsement) and greater than the Advisory Fee will be considered an Excess Withdrawal for the purpose of the recalculation of the Income Base, Maximum
Annual Withdrawal Amount [and Protected Income Payment]. ] 
 DEFINITIONS 

For purposes of this Endorsement, the following definitions apply. Terms not defined in this Endorsement shall have the same meaning as
defined in the Contract. 
 AGE 
 The
attained age as of the Covered Person’s last birthday. If there are two Covered Persons on the Endorsement Data Page, the Age of the younger Covered Person or in the event of the death of one Covered Person, the surviving Covered Person as of
their last birthday. 
 BENEFIT QUARTER 
 Each
consecutive 3-month period starting on the Endorsement Effective Date. 
 BENEFIT QUARTER ANNIVERSARY 

The date following each consecutive 3-month period starting on the Endorsement Effective Date. If the next Benefit Quarter Anniversary has no
corresponding date the Benefit Quarter Anniversary will be deemed to be the following day. 
 

 
 BENEFIT [YEAR] 
 Each
consecutive [one year] period starting on the Endorsement Effective Date. 
 BENEFIT [YEAR] ANNIVERSARY 

The date on which each Benefit [Year] begins. 
 COVERED
PERSON(S) 
 The person(s) named on the Endorsement Data Page whose lives are used to determine the amount and duration of Withdrawals.
The Covered Person(s) cannot be changed. 
 EARLIEST CANCELLATION DATE OF THE GUARANTEED LIVING BENEFIT 

The earliest Benefit Year Anniversary is as shown on the Endorsement Data Page. This is the earliest date You may cancel this Endorsement. 

ENDORSEMENT EFFECTIVE DATE 
 The date when this
Endorsement becomes effective as shown on the Endorsement Data Page. 
 EXCESS WITHDRAWAL 

Any Withdrawal in a Benefit

[Year] taken after the Maximum Annual Withdrawal Amount has been withdrawn and/or any portion of a Withdrawal that causes the total Withdrawals in a Benefit

[Year] to exceed the Maximum Annual Withdrawal Amount. 
 INCOME BASE 

The Income Base is used to determine the Endorsement Fee, the Maximum Annual Withdrawal Amount and the Protected Income Payment. 

MAXIMUM ANNUAL WITHDRAWAL AMOUNT 
 The
maximum amount that may be withdrawn each Benefit

[Year] while the Contract Value is greater than zero and the Covered Person(s) is living, without reducing the Income Base. 

MAXIMUM ANNUAL WITHDRAWAL PERCENTAGE 

  

					
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	  	3	  	

 The percentage, as referenced on the Endorsement Data Page used to determine the Maximum Annual
Withdrawal Amount available for Withdrawal each Benefit

[Year] while the Contract Value is greater than zero and the Covered Person(s) is living. 
 PROTECTED INCOME PAYMENT

 The amount to be paid each

[year] over the remaining lifetime of the Covered Person(s) after the Contract Value is reduced to zero but the Income Base is still greater than zero. 

PROTECTED INCOME PAYMENT PERCENTAGE 
 The percentage, as
referenced on the Endorsement Data Page, used to determine the Protected Income Payment. 
 STEP-UP VALUE 

A value used to determine the Income Base that is equal to the current Contract Value if it is greater than the current Income Base. This value
is determined based on the Frequency and Dates of Income Base Step-ups, as shown on the Endorsement Data Page. 
 YOU, YOUR 

The Covered Person(s) under this Endorsement. 

GUARANTEED LIVING BENEFIT PROVISIONS 

The Guaranteed Living Benefit described in this Endorsement provides for guaranteed Withdrawals over the lifetime of the Covered Person(s),
subject to the following provisions: 
 Calculation of the Factors of the Guaranteed Living Benefit 

To determine the Guaranteed Living Benefit, We use the following factors: Income Base, Maximum Annual Withdrawal Amount, Maximum Annual
Withdrawal Percentage, Protected Income Payment and Protected Income Payment Percentage. These factors are not used in the calculation of the Contract Value or any other benefits under the Contract. 

Withdrawals taken under this Living Benefit are treated like any other Withdrawal under the Contract for purposes of calculating Contract
Value, including any fees and charges applicable to any other benefits under the Contract. In any Benefit Year, Withdrawals up to Maximum Annual Withdrawal Amount are not subject to the Benefit Withdrawal Charge shown on the Endorsement Data Page.

 Calculation of the Income Base 
 The initial
Income Base is equal to the initial Purchase Payment. 
 Thereafter, if no Withdrawals have been taken, the Income Base is increased
to the Step-up Value, based on the Frequency and Dates of Income Base Step-ups. 
 After the first Withdrawal has been taken, the
Income Base is increased only on the Benefit Year Anniversary looking back to the Step-up Value based on the Frequency and Dates of Income Base Step-ups since the first Withdrawal (“first look-back”). 

After the first look-back, the Income Base is increased only on the Benefit Year Anniversary looking back to the Step-up Value
based on the Frequency and Dates of Income Base Step-ups since the last Benefit Year Anniversary. Thereafter, the Income Base will continue to be determined on each Benefit

[Year] Anniversary while this Endorsement is in effect and both the Contract Value and Income Base are greater than zero. 

Calculation of the Maximum Annual Withdrawal Amount 

The Maximum Annual Withdrawal Amount is calculated by multiplying the Income Base by the Maximum Annual Withdrawal Percentage as shown on the
Endorsement Data Page, which is determined by the timing and Your Age at the time You first take a Withdrawal from Your Contract and the number of Covered Person(s) shown on the Endorsement Data Page. 

Withdrawals during a Benefit Year that in total are less than or equal to the Maximum Annual Withdrawal Amount will not reduce the Maximum
Annual Withdrawal Amount and the Income Base. If You choose to take less than the Maximum Annual Withdrawal Amount in any Benefit Year, You may not carry over the unused amount for withdrawal in subsequent Benefit Years. Your Maximum Annual
Withdrawal Amount in any year will not be recalculated solely as a result of taking less than the entire Maximum Annual Withdrawal Amount in the prior Benefit Year. 

  

					
	 USLE-8043 (4/16)
	  	4	  	

 Calculation of the Protected Income Payment 

If the Contract Value is reduced to zero due to unfavorable investment performance, Withdrawal up to the Maximum Annual Withdrawal Amount, or
any combination of these factors, but the Income Base is still greater than zero, You may be eligible to receive the Protected Income Payment. The Protected Income Payment is calculated by multiplying the Income Base by the applicable Protected
Income Payment Percentage, which is determined by Your Age at the time You first take a Withdrawal from Your Contract, as shown on the Endorsement Data Page. You will receive the Protected Income Payment each year for the remaining lifetime of the
Covered Person(s). 
 Increases and Decreases in the Income Base and the Impact to Your Maximum Annual Withdrawal Amount 

Increases in the Income Base 
 The Income
Base is increased as a result of a Step-up Value being achieved resulting in the Income Base being stepped up on: (1) the Frequency and Dates of Income Base Step-ups prior to taking any Withdrawals, or (2) a Benefit Year Anniversary after
Withdrawals have been taken. The Income Base is also increased when a Purchase Payment is allocated to Your Contract subject to the Purchase Payment Restriction shown on the Endorsement Data Page; consequently, any remaining 

Withdrawals of the Maximum Annual Withdrawal Amount will be based on the increased Maximum Annual Withdrawal Amount reduced by Withdrawals
previously taken in that Benefit

[Year]. When the Income Base is increased as referenced in (1) and (2) above, the Maximum Annual Withdrawal Amount will be recalculated by multiplying the increased Income Base by the applicable Maximum Annual
Withdrawal Percentage. The Endorsement Fee will be assessed on the increased Income Base. 
 Decreases in the Income Base 

Excess Withdrawals reduce Your Income Base on the date the Excess Withdrawal occurs. Any Excess Withdrawal in a Benefit

[Year] reduces the Income Base in the same proportion by which the Contract Value is reduced by the Excess Withdrawal. As a result of a reduction of the Income Base, the Maximum Annual Withdrawal Amount will also be
reduced. The new Maximum Annual Withdrawal Amount will be equal to the reduced Income Base multiplied by the applicable Maximum Annual Withdrawal Percentage. The last recalculated Maximum Annual Withdrawal Amount in a given Benefit

[Year] is available for Withdrawal at the beginning of the next Benefit

[Year] and may be lower than the previous Benefit

[Year]’s Maximum Annual Withdrawal Amount. When the Contract Value is less than the Income Base, Excess Withdrawals will reduce the Income Base by an amount which is greater than the amount of the Excess Withdrawal.

 The Income Base is a factor used to determine the Maximum Annual Withdrawal Amount and Protected Income Payment as well as the
Endorsement Fee. The Income Base is not an amount that You can withdraw. Excess Withdrawals may reduce future benefits by more than the dollar amount of the Withdrawal. Excess Withdrawals will incur a Charge for Partial/Full Termination if they
occur during the applicable period indicated on the Endorsement Data Page. If You have any questions regarding whether a potential Withdrawal would be an Excess Withdrawal, please call Our Annuity Service Center. 

Required Minimum Distributions (RMD) 

This provision applies only to the Contract to which this Endorsement is attached. If you are taking RMD and the RMD amount, based only
on this Contract, is greater than the Maximum Annual Withdrawal Amount in any given Benefit

[Year], no portion of the RMD will be treated as an Excess Withdrawal provided you enroll in the Company’s systematic withdrawal program for RMD. However, any portion of a Withdrawal in a Benefit

[Year] that is more than the greater of both the Maximum Annual Withdrawal Amount and the RMD amount will be considered an Excess Withdrawal for the purpose of the recalculation of the Income Base and Maximum Annual
Withdrawal Amount. 
 If Your Contract Value Is Reduced to Zero 

If Your Contract Value is reduced to zero because of an Excess Withdrawal, no further benefits will be payable under this Endorsement or the
Contract, and Your Contract along with the Endorsement will terminate. However, if Your Contract Value is reduced to zero due to unfavorable investment performance and/or fees, Withdrawal(s) up to the Maximum Annual Withdrawal Amount (or if
applicable, the RMD amount as described above) or any combination of these factors, and the Income Base is greater than zero, We will pay the remaining Maximum Annual Withdrawal Amount for that Benefit

[Year] in the same frequency withdrawals had been taken, i.e. monthly or quarterly. Thereafter, we will pay the Protected Income Payment over the remaining lifetime of the Covered Person(s) which will be calculated by
multiplying the Income Base by the Protected Income Payment Percentage, as shown on the Endorsement Data Page. 
 Because the Contract Value
has been reduced to zero, the Income Base will no longer be increased to a Step-up Value and no Endorsement Fees will be deducted. In addition, all other benefits under the Contract with the exception of payment of the Protected Income Payment, will
be terminated and You may no longer make subsequent Purchase Payments or transfers, and no Death Benefit is payable. 

  

					
	 USLE-8043 (4/16)
	  	5	  	

 When the Contract Value equals zero and the Income Base is greater than zero, to receive any
remaining Living Benefit, you must select one of the following payment options: 
  

	 	1.	 The Protected Income Payment, divided equally and paid on a monthly, quarterly, semi-annual or annual
frequency as selected by You until the date of Your death(s); or 

  

	 	2.	 Any payment option mutually agreeable between You and Us. 

Once You select a payment option, it cannot be changed. If You do not select a payment option above, the remaining benefit will be paid as an
amount based on the Protected Income Payment Percentage. This amount will be divided equally and paid on a quarterly basis until the date of death of the Covered Person(s). 

Latest Annuity Date 
 If the Contract
Value and the Income Base are greater than zero on the Latest Annuity Date, You must select one of the following options: 
  

	 	1.	 Annuitize the Contract Value under the Annuity Provisions of the Contract; or 

 

	 	2.	 Annuitize the Contract and elect to receive the current Maximum Annual Withdrawal Amount as of the Latest
Annuity Date for a fixed period while You are alive. The fixed period is determined by dividing the contract value on the Latest Annuity Date by the Maximum Annual Withdrawal Amount. Any applicable premium taxes will be deducted from the Contract
Value prior to determining the fixed period. After that fixed period ends, you will receive the Protected Income Payment, as of the Latest Annuity Date, divided equally and paid on a monthly, quarterly, semi-annual or annual frequency as selected by
You until the date of death of the Covered Person(s); or 

  

	 	3.	 Any payment option mutually agreeable between You and Us. 

If You do not select an option listed above, on the Latest Annuity Date, We may annuitize the Contract Value in accordance with Option 2
above, divided equally and paid on a

[quarterly] frequency until the date of death of the Covered Person(s). Endorsement Fees are no longer deducted upon annuitization on the Latest Annuity Date. 

[Secure Value Account Allocation(s) 
 If
applicable, Secure Value Account Allocation(s) is/are required only while the Endorsement is effective. Amounts allocated to the Secure Value Account(s) are not subject to the Separate Account Charge. Amounts allocated to the Secure Value Account(s)
may not be transferred to any other investment option as long as the Endorsement is effective and We will not rebalance amounts allocated to the Secure Value Account(s) in accordance with the automatic asset rebalancing program. You may not transfer
into or out of the Secure Value Account(s). You may not request the entire amount of any Withdrawal to be deducted solely from the Secure Value Account(s). Rather, any Withdrawal reduces the amount invested in the Secure Value Account(s) in the same
proportion that the Withdrawal reduces the Contract Value.]

 
 [Investment Requirements 

If applicable, in addition to the Secure Value Account Allocation, while the Endorsement is effective, We require that you allocate your
Purchase Payment(s) and Spousal Beneficiary Continuation contribution, if applicable, and Contract Value in accordance with established requirements stated in the Prospectus. We require enrollment in a quarterly automatic asset rebalancing program
that complies with the investment requirements. In addition to quarterly asset rebalancing, We will initiate rebalancing in accordance with your most current and compliant automatic asset rebalancing instructions on file after any Withdrawal or
transfer You initiate.]

 
 Misstatement of Age or Sex 

The Misstatement of Age or Sex provision included in Your Contract shall apply to the Covered Person(s) under this Endorsement and may impact
the Maximum Annual Withdrawal Amount. 
 Termination of Withdrawals Over Two Lives 

If there are two Covered Persons on the Endorsement Effective Date, Withdrawals guaranteed for the life of one of the Covered Persons will
terminate if: 
  

	 	1.	 One of the two Covered Persons is removed from the Endorsement due to any reason other than death; or

  

	 	2.	 The Covered Persons are no longer married at the time of death of the first Covered Person.

 Termination of Withdrawals guaranteed for the life of one Covered Person does not impact any other terms and conditions
of this Endorsement, including the applicable Endorsement Fee, which is based on the number of Covered Persons on this Endorsement Effective Date. 

  

					
	 USLE-8043 (4/16)
	  	6	  	

 Cancellation of the Guaranteed Living Benefit 

You may cancel this Endorsement as detailed below on or after the Earliest Cancellation Date of the Guaranteed Living Benefit as shown on the
Endorsement Data Page. You may cancel this Endorsement by means of a Written request as detailed below. The Guaranteed Living Benefit may not be re-elected or reinstated after a cancellation. 

Cancellation Effective Date 
 If Your cancellation request
is received: 
  

	 	1.	 On or before the Earliest Cancellation Date of the Guaranteed Living Benefit, the cancellation is effective on
the Earliest Cancellation Date of the Guaranteed Living Benefit date as shown on the Endorsement Data Page; 

	 	2.	 In any Benefit Year after the Earliest Cancellation Date of the Guaranteed Living Benefit date, the
cancellation is effective on the Benefit Quarter Anniversary following Our receipt of the cancellation request. 

 Termination of
the Guaranteed Living Benefit 
 This Endorsement and the Endorsement Fee will terminate automatically upon the occurrence of one of the
following: 
  

	 	1.	 Death of the Covered Person, or if there were two Covered Persons, upon the death of the surviving Covered
Person; or 

	 	2.	 A Death Benefit is paid resulting in the Contract being terminated; or 

	 	3.	 The Contract is annuitized; or 

	 	4.	 An Excess Withdrawal that reduces the Contract Value and Income Base to zero; or 

	 	5.	 Any change occurs that removes one or all Covered Persons from the Contract except as noted above under
“Termination of Withdrawals Over Two Lives”; or 

	 	6.	 The Contract is cancelled or surrendered for any reason; or 

	 	7.	 Assignment of any Contract Owner rights under this Endorsement to a third party; or 

	 	8.	 You elect to cancel this Endorsement. 

On the termination effective date, amounts allocated to the Secure Value Account will be automatically transferred to a

[1-Year Fixed Account option, if available, or a money market or similar portfolio]. Purchase Payments may no longer be allocated to the Secure Value Account after termination. From the day following the automated
transfer, you may transfer this amount to another available investment option under the Contract for a period of [90 days]

 during which the transfer will not count against the annual number of free transfers or incur a transfer fee. 

If You surrender Your Contract while Your Contract Value is greater than zero, We will assess a pro-rata charge for the Endorsement Fee
applicable to the Benefit

[Quarter] in which the surrender occurs if the Contract was surrendered before the end of a Benefit

[Quarter]. The pro-rated charge is calculated by multiplying the fee by the number of days between the date when the prior fee was last assessed and the date of surrender, divided by the number of days between the prior
and the next Benefit

[Quarter] Anniversaries. Thereafter, You will no longer be charged an Endorsement Fee. If You surrender Your Contract, You will also incur a Benefit Withdrawal Charge if You take a total Withdrawal of all Your Contract
Value during the applicable period indicated on the Endorsement Data Page. 
 Death of Covered Person(s) 

If there is one Covered Person and that person dies, this Endorsement and the Endorsement Fee will be terminated. 

If there are two Covered Persons, upon the first death, if the surviving Covered Person is eligible and elects to continue the Contract, this
Endorsement is also continued. Upon the election of continuation, the Endorsement Effective Date, the applicable Endorsement Fee, and the Maximum Annual Withdrawal and Protected Income Payment Percentages based on two Covered Persons will not
change. 
 Signed for the Company to be effective on the Endorsement Effective Date. 

THE UNITED STATES LIFE INSURANCE COMPANY IN THE CITY OF NEW YORK 
 

 
 

 

  

					
	 USLE-8043 (4/16)
	  	7EX-(4).(d)

 THE UNITED STATES LIFE INSURANCE COMPANY IN THE CITY OF NEW YORK 

INDIVIDUAL RETIREMENT ANNUITY ENDORSEMENT 

This Endorsement amends the Contract or Certificate (“Contract”) to which it is attached so that it may qualify as an Individual
Retirement Annuity (IRA) under Section 408(b) of the Internal Revenue Code (Code) and the Regulations under that Section. The endorsement may be amended from time to time to comply with changes in the Internal Revenue Code. Any such change would be
subject to New York State Department of Insurance approval. The Owner or Participant (“Owner”) has the right to refuse to accept any such amendment; however, We shall not be held liable for any tax consequences incurred by the Owner as a
result of such refusal. In the case of a conflict with any provision in the Contract, including the terms of any other riders or endorsements to the Contract, the provisions of this Endorsement will control. The effective date of this Endorsement is
the Contract Date shown on the Contract Data Page. The Contract is amended as follows: 
  

	1.	 The Owner, Annuitant and Payee shall be the same individual. The Owner, Annuitant and Payee cannot be
changed, except as otherwise permitted under the Code and applicable regulations. All distributions made while the Owner is alive must be made to the Owner. 

 

	2.	 The interest of the Owner under this Contract shall be nonforfeitable except as provided by law.

  

	3.	 This Contract may not be sold, assigned, discounted, pledged as collateral for a loan or as security for the
performance of any obligation or for any other purpose, or otherwise transferred (other than a transfer incident to a divorce or separation instrument in accordance with Section 408(d)(6) of the Code) to any person other than to the Company.

  

	4.	 This Contract is established for the exclusive benefit of the Owner and his or her Beneficiary(ies). If
this is an inherited IRA within the meaning of Code § 408(d)(3)(C) maintained for the benefit of a designated beneficiary of a deceased Owner, references in this Endorsement to the “Owner” are to the deceased Owner.

  

	5.	Purchase Payment(s) are flexible. You may change the amounts, frequency and/or timing of Purchase Payments. 

  

	6.	 (a) Except in the case of a rollover contribution (as permitted by Code§ 402(c), 402(e)(6),
403(a)(4), 403(b)(8), 403(b)(10), 408(d)(3) and 457(e)(16)) or a contribution made in accordance with the terms of a Simplified Employee Pension (SEP) as described in § 408(k), no contributions will be accepted unless they are in cash, and
the total of such contributions shall not exceed $5,000 for any taxable year beginning in 2008 and years thereafter. 

After 2008, the limit will be adjusted by the Secretary of the Treasury for cost-of-living increases under Code § 219(b)(5)(D). Such
adjustments will be in multiples of $500. 
 (b) In the case of an individual who is age 50 or older, the annual cash
contribution limit is increased by $1,000 for any taxable year beginning in 2006 and years thereafter. 
 (c) In addition to
the amounts described in paragraphs (a) and (b) above, an individual may make additional contributions specifically authorized by statute – such as repayments of qualified reservist distributions, repayments of certain plan distributions made
on account of a federally declared disaster and certain amounts received in connection with the Exxon Valdez litigation. 

  

					
	 USLE-6171 (12/15)
	  	1	  	

 (d) In addition to the amounts described in paragraphs (a) and (c) above, an
individual who was a participant in a Code § 401(k) plan of a certain employer in bankruptcy described in Code § 219 (b)(5)(C) may contribute up to $3,000 for taxable years beginning after 2006 and before 2010 only. An individual who
makes contributions under this paragraph (d) may not also make contributions under paragraph (b). 
 (e) No contributions
will be accepted under a SIMPLE IRA plan established by any employer pursuant to Code § 408(p). Also, no transfer or rollover of funds attributable to contributions made by a particular employer under its SIMPLE IRA plan will be accepted
from a SIMPLE IRA, that is, an IRA used in conjunction with a SIMPLE IRA plan, prior to the expiration of the 2-year period beginning on the date the Owner first participated in that employer’s SIMPLE IRA plan. 

(f) If this is an inherited IRA within the meaning of Code § 408(d)(3)(C), no contributions will be accepted. 

 

	7.	 Any refund of premiums (other than those attributable to excess contributions) will be applied, before the
close of the calendar year following the year of the refund, toward the payment of future premiums or the purchase of additional benefits. 

  

	8.	 (a) Notwithstanding any provision of this IRA to the contrary, the distribution of the Owner’s interest
in the IRA shall be made in accordance with the requirements of Code § 408(b)(3) and the regulations thereunder, the provisions of which are herein incorporated by reference. If distributions are not made in the form of an annuity on
an irrevocable basis (except for acceleration), then distribution of the interest in the IRA (as determined under section 9(c)) must satisfy the requirements of Code § 408(a)(6) and the regulations thereunder, rather than paragraphs
(b), (c) and (d) below and section 9. 

 (b) The entire interest of the Owner for whose benefit the
Contract is maintained will commence to be distributed no later than the first day of April following the calendar year in which such Owner attains age 70 1⁄2
(the “required beginning date”) over: (a) the life of such individual or the lives of such individual and his or her designated beneficiary or (b) a period certain not extending beyond the life expectancy of such individual or the joint
and last survivor expectancy of such individual and his or her designated beneficiary. Payments must be made in periodic payments at intervals of no longer than 1 year and must be either nonincreasing or they may increase only as provided in
Q&As-1 and -4 of § 1.401(a)(9)-6 of the Income Tax Regulations. In addition, any distribution must satisfy the incidental benefit requirements specified in Q&A-2 of § 1.401(a)(9)-6. If this is an inherited IRA within the
meaning of Code § 408(d)(3)(C), this paragraph and paragraphs (c) and (d) below do not apply. 
 (c) The distribution
periods described in paragraph (b) above cannot exceed the periods specified in § 1.401(a)(9)-6 of the Income Tax Regulations. 

(d) The first required payment can be made as late as April 1 of the year following the year the individual attains age 70 1⁄2 and must be the payment that is required for one payment interval. The second payment need not be made until the end of the next payment interval. 

 

	9.	 Unless otherwise permitted under applicable law, upon the death of the Owner: 

(a) Death On or After Required Distributions Commence. If the Owner dies on or after required distributions commence, the
remaining portion of his or her interest will continue to be distributed under the Contract option chosen. 

  

					
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 (b) Death Before Required Distributions Commence. If the Owner dies before
required distributions commence, his or her entire interest will be distributed at least as rapidly as follows: 
 (1) If
the designated beneficiary is someone other than the Owner’s surviving spouse, the entire interest will be distributed, starting by the end of the calendar year following the calendar year of the Owner’s death, over the remaining life
expectancy of the designated beneficiary, with such life expectancy determined using the age of the beneficiary as of his or her birthday in the year following the year of the Owner’s death, or, if elected, in accordance with paragraph (b)(3)
below. If this is an inherited IRA within the meaning of Code § 408 (d)(3)(C) established for the benefit of a nonspouse designated beneficiary by a direct trustee-to-trustee transfer from a retirement plan of a deceased individual under Code
§ 402(c)(11), then, notwithstanding any election made by the deceased individual pursuant to the preceding sentence, the nonspouse designated beneficiary may elect to have distributions made under this paragraph (b)(1) if the transfer is made
no later than the end of the year following the year of death. 
 (2) If the Owner’s sole designated beneficiary is the
Owner’s surviving spouse, the entire interest will be distributed, starting by the end of the calendar year following the calendar year of the Owner’s death (or by the end of the calendar year in which the Owner would have attained age 70 1⁄2, if later), over such spouse’s life or over a period not extending beyond such spouse’s life expectancy, or, if elected, in accordance with paragraph
(b)(3) below. If the surviving spouse dies before required distributions commence to him or her, the remaining interest will be distributed, starting by the end of the calendar year following the calendar year of the spouse’s death, over the
spouse’s designated beneficiary’s remaining life expectancy determined using such beneficiary’s age as of his or her birthday in the year following the death of the spouse, or, if elected, will be distributed in accordance with
paragraph (b)(3) below. If the surviving spouse dies after required distributions commence to him or her, any remaining interest will continue to be distributed under the Contract option chosen. 

(3) If there is no designated beneficiary, or if applicable by operation of paragraph (b)(1) or (b)(2) above, the entire
interest will be distributed by the end of the calendar year containing the fifth anniversary of the Owner’s death (or of the spouse’s death in the case of the surviving spouse’s death before distributions are required to begin under
paragraph (b)(2) above). 
 (4) Life expectancy is determined using the Single Life Table in Q&A-1 of
§ 1.401(a)(9)-9 of the Income Tax Regulations. If distributions are being made to a surviving spouse as the sole designated beneficiary, such spouse’s remaining life expectancy for a year is the number in the Single Life Table
corresponding to such spouse’s age in the year. In all other cases, remaining life expectancy for a year is the number in the Single Life Table corresponding to the beneficiary’s age in the year specified in paragraph (b)(1) or (2) and
reduced by 1 for each subsequent year. 
 (c) The “interest” in the IRA includes the amount of any outstanding
rollover, transfer and recharacterization under Q&As-7 and -8 of § 1.408-8 of the Income Tax Regulations and the actuarial value of any other benefits provided under the IRA (prior to annuitization), such as guaranteed death benefits.

 (d) For purposes of paragraphs (a) and (b) above, required distributions are considered to commence on the Owner’s
required beginning date or, if applicable, on the date distributions are required to begin to the surviving spouse under paragraph (b)(2) above. However, if distributions start prior to the applicable date in the preceding sentence, on an
irrevocable basis (except for acceleration) under an annuity contract meeting the requirements of § 1.401(a)(9)-6 

  

					
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of the Income Tax Regulations, then required distributions are considered to commence on the annuity starting date. 

(e) If the sole designated beneficiary is the Owner’s surviving spouse, the spouse may elect to treat the IRA as his or
her own IRA. This election will be deemed to have been made if such surviving spouse makes a contribution to the IRA or fails to take required distributions as a beneficiary. 

(f) The required minimum distributions payable to a designated beneficiary from this IRA may be withdrawn from another IRA the
beneficiary holds from the same decent in accordance with Q&A-9 of § 1.408-8 of the Income Tax Regulations. 
  

	10.	 The Company shall furnish annual calendar year reports concerning the status of the annuity and such
information concerning minimum required distributions as is prescribed by the Commissioner of Internal Revenue. 

  

	11.	 Except to the extent Treasury regulations allow Us to offer additional Annuity Payment Options that are
acceptable to Us, only the Annuity Payment Options as described in the Contract shall be offered unless We consent to the use of an additional option. 

Any additional Annuity Payment Option under the Contract must meet the requirements of section 408(b) of the Code and
applicable regulations. The provisions of this Endorsement reflecting the requirements of Code Sections 401(a)(9) and 408(b) override any additional Annuity Payment Option inconsistent with such requirements. 

If a guaranteed or specified period of payments is chosen under an Annuity Payment Option, the length of the period must not
exceed the shorter of (1) the Owner’s life expectancy, or if a designated second person is named, the joint and last survivor expectancy of the Owner and the designated second person, and (2) the applicable maximum period under Section
1.401(a)(9)-6 of the Income Tax Regulations. 
  

	12.	 If you return the Contract within 10 days after the Contract Date, the Company will refund the amount of your
Purchase Payments, without adjustment for such items as sales commissions, administrative expenses, and fluctuation in market value for the Valuation Period in which the Contract is received. 

 

	13.	 The provisions of this Endorsement are intended to comply with the requirements of the Code and applicable
regulations for IRAs under Section 408(b) of the Code. The Company reserves the right to amend the Contract and this Endorsement from time to time when such amendment is necessary to assure continued qualification of the Contract as an IRA
under Section 408(b) of the Code (and any successor provision) as in effect from time to time. The Owner has the right to refuse to accept any such amendment; however, we shall not be held liable for any tax consequences incurred by the Owner
as a result of such refusal. 

 All other terms and conditions of the Contract remain unchanged. 

Signed for the Company to be effective on the Contract Date.

THE UNITED STATES LIFE INSURANCE COMPANY IN THE CITY OF NEW YORK 
  

 

  

					
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