Document:

EX- 4.D

 EXHIBIT 4(d) 

FORM OF POLICY RIDER (TRANSAMERICA INCOME EDGE) 

							
	

	  		  	Home Office located at:	  	
	  	 	  	440 Mamaroneck Avenue, Harrison, New York 10528	  	 
	  		  		  	
	  		  	Adm. Office located at:	  	
	  	 	  	4333 Edgewood Road N.E. Cedar Rapids, Iowa 52499	  	 
	  		  	(319) 355-8511	  	 
	  		  	www.transamerica.com	  	 
	    A Stock Company (Hereafter called the Company, we, our or us)	  	 	  		  	 

 GUARANTEED LIFETIME WITHDRAWAL BENEFIT 

This rider is issued as a part of the policy to which it is attached. All provisions of the policy that do not conflict with this rider apply to this rider.
In the event of any conflict between the provisions of this rider and the provisions of the policy, the provisions of this rider shall prevail over the provisions of the policy. 

The purpose of this guaranteed living benefit provided under this annuity rider is to provide a stream of income payments to the Owner. 

You may cancel this rider on or before midnight of the thirtieth calendar day after You receive it and no Rider Fees will be assessed. Upon cancellation,
all Policy Value in the Stable Account will be transferred to the Money Market Subaccount available in Your policy. 
 This rider provides a minimum
withdrawal benefit that guarantees, upon election, a series of withdrawals from the policy equal to the Withdrawal Percentage shown below applied to the Withdrawal Base. The Withdrawal Base is established for the sole purpose of determining the
minimum withdrawal benefit and is not used in calculating the cash surrender value or other guaranteed benefits. 
  

																																													
	 RIDER DATA SPECIFICATION
	   
	 	
		  		  				 		  				  		  				 		  				  		  				 		  				  		  				 	
	 Policy Number:    
	  	 	  	 	12345	  	 	 	  				  		  				 		  				  		  				 		  				  		  				 	
	 Rider Date:    
	  		  	 	08/01/2016	  	 	 	  				  		  				 		  				  		  				 		  				  		  				 	
	 Initial Rider Fee Percentage*:    
	  	 	  	 	1.50%	  	 	 	  				  		  				 		  				  		  				 		  				  		  				 	
		  	Required Allocations
		  	Premium	  				  	Rebalance
		  		  	 	Minimum	  	 		  				  		  	 	Maximum	  	 		  				  		  	 	Minimum	  	 		  				  		  	 	Maximum	  	 	
	 Stable Account:    
	  	 	  	 	20%	  	 	 	  				  	 	  	 	20%	  	 	 	  				  		  	 	N/A	  	 		  				  		  	 	N/A	  	 	
	 Select Investment Options:    
	  		  	 	20%	  	 	 	  				  		  	 	80%	  	 	 	  				  	 	  	 	25%	  	 	 	  				  	 	  	 	100%	  	 	 
	 Flexible Investment Options:    
	  	 	  	 	0%	  	 	 	  				  	 	  	 	60%	  	 	 	  				  	 	  	 	0%	  	 	 	  				  	 	  	 	75%	  	 	 
		  			 		  				  		  				 		  				  		  				 		  				  		  				 	
	 Guaranteed Minimum Effective Annual Interest
Rate    
 for Stable Account:    
	  	[1.00%]	  	 		  				  		  				 		  				  		  				 		  				  		  				 	
		  			 		  				  		  				 		  				  		  				 		  				  		  				 	
	 Annuitant:    
	  	[John Doe]	  	 		  				  		  				 		  				  		  				 		  				  		  				 	
	 Annuitant’s Issue Age/Sex:    
	  	[65 / Male]	  	 		  				  		  				 		  				  		  				 		  				  		  				 	
		  			 		  				  		  				 		  				  		  				 		  				  		  				 	
	 Minimum Benefit Age:    
	  	[59]	  	 		  				  		  				 		  				  		  				 		  				  		  				 	

  

	*	The initial rider fee percentage is for the life of the rider, provided there are no automatic step-ups. When an automatic step-up occurs, the rider fee percentage will never be increased by more than [0.75%] greater
than the initial rider fee percentage shown above. Therefore, the maximum rider fee percentage will never be greater than the initial rider fee percentage, plus [0.75%]. 

Guaranteed Lifetime Withdrawal Benefit: The withdrawal percentage is used to determine the Rider Withdrawal Amount as described in Article III of this
rider. The withdrawal percentages are shown in the table below. 

  

					
	NIC16 RGMB510616(IS)(NY)	  	(1)	  	(Income-Single)

																													
	Withdrawal Percentage
		 		 		 		 		 		  		  		  		 		  		  		  		 		  	
		 	 Attained Age
	 		 		 		 	[Rider Years 1-5]	  		  		  		 	[Rider Years 6-10]	  		  		  		 	[Rider Years 11+]	  	
	 	 	 59-64
	 	 	 		 	 	 	4.0%	  	 	  		  	 	 	5.0%	  	 	  		  	 	 	6.0%	  	 
	 	 	 65-79
	 	 	 		 		 	5.0%	  	 	  		  		 	6.0%	  	 	  		  		 	7.0%	  	 
	 	 	 80+
	 	 	 		 	 	 	6.0%	  	 	  		  	 	 	7.0%	  	 	  		  	 	 	8.0%	  	 

 ARTICLE I 

DEFINITIONS: 
 Terms used that are not defined in this
rider shall have the same meaning as those in Your policy. 
 Excess Withdrawal 

The excess of a Gross Partial Withdrawal over the Rider Withdrawal Amount remaining prior to the withdrawal, if any. 

Flexible Investment Options 
 A designated group of
Investment Options identified by us to which You must allocate a portion of Your Premium Payments and Policy Value as shown on page 1 of this rider and as described in Article II. You will be notified if there are changes made to the Investment
Options within the designated group. 
 Gross Partial Withdrawal 

The amount that will be deducted from Your Policy Value as a result of each partial withdrawal. 

Rider Anniversary 
 The anniversary of the rider date.

 Rider Fee 
 The fees charged for the benefits under
this rider. 
 Rider Quarter 
 Each successive
three-month period beginning on the rider date. 
 Rider Quarterversary 

For each Rider Quarter, the same day of the month as the rider date, or the next business day if our Administrative Office or the New York Stock Exchange is
closed. If a certain date does not exist in a given month, the first day of the following month will be used. 
 Rider Withdrawal Amount 

The maximum amount that can be withdrawn from the policy each Rider Year without causing an Excess Withdrawal under the terms of this rider and thus reducing
the Withdrawal Base. This amount will change if the Withdrawal Base or Withdrawal Percentage changes. 
 Rider Year 

Each twelve-month period following the rider date. 
 Stable
Account 
 The Stable Account is a Fixed Account Option under Your policy, only available if You elect this rider, to which You must allocate a portion
of Your Premium Payments and Policy Value shown on page 1 of this rider. Allocations applied to the Stable Account will be credited interest based on a fixed rate. The interest rates will be credited for increments of at least one year measured from
each Premium Payment date and will automatically renew and remain in the Stable Account. These rates will never be less than the Guaranteed Minimum Effective Annual Interest Rate for Stable Account shown on page 1 of this rider. 

Select Investment Options 
 A designated group of
Investment Options identified by us to which You must allocate a portion of Your Premium Payments and Policy Value shown on page 1 of this rider and as described in Article II. You will be notified if there are changes made to the Investment Options
within the designated group. 

  

					
	NIC16 RGMB510616(IS)(NY)	  	(2)	  	(Income-Single)

 ARTICLE I CONTINUED 

Withdrawal Base 
 The amount used to calculate the Rider
Withdrawal Amount and the Rider Fee. This amount has no cash value and cannot be taken as a lump sum. 
 ARTICLE II 

REQUIRED ALLOCATIONS 
 If You elect this rider, a certain
percentage of Your Policy Value on the rider date must be allocated to the Stable Account, the Select Investment Options and the Flexible Investment Options, as specified for premiums in the Required Allocations shown on page 1, in the Rider Data
Specification section. Any transfers to and from the Select Investment Options and Flexible Investment Options will be validated using the prior day’s Policy Values to ensure compliance as specified for rebalancing in the Required Allocations
shown on page 1, in the Rider Data Specification section, at the time of the request. Changes in Policy Values due to market movements on other dates will not be treated as a violation of the Required Allocations. After the rider date, the
allocation of all Premium Payments made (and any Premium Enhancements, if applicable to Your policy) must also comply with the Required Allocations, so long as this rider is effective. No further change or limitation of the available investment
options will be made without prior approval of the New York Department of Financial Services. 
 Transfers to and from the Stable Account are not permitted.
Withdrawals from the Stable Account are not permitted until all other Investment Options are depleted of value. Withdrawals from the Flexible Investment Options and Select Investment Options will be deducted on a pro-rata basis. If You do not wish
to maintain the Required Allocations shown on page 1, in the Rider Data Specification section, this rider must be terminated, subject to the restrictions and requirements as described in Article IV, prior to making any transfer. 

Enrollment in Dollar Cost Averaging is not available while this rider is in effect. 

REBALANCING 
 While this rider is effective, quarterly
Rebalancing is required and will take place at the end of each successive Rider Quarter on the same date Your Rider Fee is deducted. If the day Rebalancing takes place is not a Market Day, the value of accumulation units redeemed or purchased due to
Rebalancing will be determined as of the next Market Day. We will automatically transfer amounts among Subaccounts according to the most recent rebalancing allocation instructions on file that comply with the Required Allocations for Rebalancing as
shown on page 1, in the Rider Data Specification section. On the rider date, Your rebalancing allocation instructions will be established by applying a ratio of Your current investment allocation instructions for new premium. Because the Stable
Account is not included in the quarterly rebalancing process and whole percentages are required, it may be necessary for the company to make adjustments (positive or negative) to the calculated rebalance allocation percentages to accommodate for
rounding to the nearest whole percent. Adjustments needed will be applied to the Select Investment Options and Flexible Investment Options individually to ensure the requirements for each designated group are met. Any adjustments will first be made
to the Subaccount with the greatest percentage allocation. If more than one Subaccount has the greatest percentage allocation, the adjustment will be divided equally among those Subaccounts with the greatest percentage allocation. If the adjustment
cannot be divided equally, we will make adjustments in alphabetical order to the Subaccount(s) with the greatest percentage allocation. You will be notified in writing of the calculated rebalance allocation percentages prior to the first quarter
Rebalancing. You may request changes to Your rebalancing allocation instructions while this rider remains effective as long as they comply with the required rebalance allocations. Rebalancing will not cease upon the request of any transfer. 

Please see the Appendix attached to this rider which illustrates the initial calculation of rebalancing allocation percentages as well as the rebalancing
process. 
 RIDER FEE 
 The Rider Fee is deducted on
each successive Rider Quarterversary, on the same day of the month as the rider date. If a day does not exist in a given month, the first day of the following month will be used. If a Rider Fee is deducted from the Flexible Investment Options and
Select Investment Options on a day which is not a Market Day, the value of accumulation units redeemed will be determined as of the next Market Day. The Rider Fee is calculated and stored at issue and at each subsequent Rider Quarterversary for the
upcoming Rider Quarter. It will be deducted automatically from Flexible Investment Options and Select Investment Options, on a pro rata basis, on each Rider Quarterversary. The initial rider fee percentage is shown and the maximum rider fee
percentage is described on page 1, in the Rider Data Specification section. The rider fee percentage will not change during the first Rider Year, and will only change thereafter due to an automatic step-up. You will be notified of any increase in
the rider fee percentage. If this rider is terminated prior to the end of a Rider Quarter, a portion of the fee will also be deducted based on the number of days that have elapsed since the end of the previous Rider Quarterversary. 

  

					
	NIC16 RGMB510616(IS)(NY)	  	(3)	  	(Income-Single)

 ARTICLE II CONTINUED 

The quarterly Rider Fee is calculated as follows: 
 Multiply
(1) by (2) by (3), where: 
  

	1)	is Withdrawal Base; 

  

	2)	is rider fee percentage; 

  

	3)	is number of days in the Rider Quarter divided by the number of days within the applicable Rider Year 

 The fee
will be adjusted if the Withdrawal Base is adjusted during the Rider Quarter. The fee adjustments are calculated as follows: 
 Multiply (1) by
(2) by (3), where: 
  

	1)	is the change in Withdrawal Base; 

  

	2)	is rider fee percentage; 

  

	3)	is number of days remaining in the Rider Quarter divided by the number of days within the applicable Rider Year. 

Please see the Appendix attached to this rider which illustrates how the Rider Fee is calculated. 

ARTICLE III 
 GUARANTEED LIFETIME WITHDRAWAL
BENEFIT 
 Under this rider, we guarantee that You can receive up to the Rider Withdrawal Amount each Rider Year, regardless of the Policy Value, (first
as withdrawals from Your Policy Value and, if necessary, as payments from us) until the Annuitant’s death. This rider requires the Annuitant to also be an Owner, except in the case of non-natural Owners. Such non-natural Owners must be
established for the benefit of the Annuitant. Once this rider is issued the Annuitant cannot be changed, except when the underlying Individual Retirement Annuity (IRA) policy is transferred pursuant to a divorce. In the event of a divorce, this
rider will continue provided the Annuitant remains an Owner. 
 Withdrawals will reduce the Policy Value and death benefit of the policy to which this rider
is attached. If the Policy Value equals zero, You cannot make subsequent Premium Payments and all other policy features, benefits and guarantees are no longer available. Also, if the Policy Value equals zero and the rider remains inforce, we will,
unless instructed otherwise, make payments using the current payment instructions on file with us equal to the Rider Withdrawal Amount divided by the frequency of payments. If the Annuitant has attained the minimum benefit age and a systematic
payout option is not active at the time the Policy Value equals zero, a monthly payment will begin. If the minimum benefit age has not been attained, the monthly payment will begin on the Rider Anniversary following the attainment of the minimum
benefit age. Once the payment amount and frequency are established, they cannot be changed and no additional withdrawals will be allowed. We have the right to reasonably require satisfactory evidence a person is alive if payment is based on that
person being alive. 
 While this rider is in-force, we will not invoke the Involuntary Cashout provision of the policy to which this rider is attached if
this rider has a Withdrawal Base of $2,000 or greater. 
 We guarantee that You may withdraw up to the Rider Withdrawal Amount each year regardless of the
Policy Value until the Annuitant’s death. 
 Example 

Assume You are the Owner and Annuitant and begin taking withdrawals at age 80 and Your Withdrawal Base is $100,000. Assuming a withdrawal
percentage of 6.00%, You could withdraw up to $6,000 during Rider Years 1-5 (assuming that You do not withdraw more than $6,000 during those Rider Years). 

Any amount You withdraw in excess of the Rider Withdrawal Amount may impact the Withdrawal Base on a greater than dollar-for-dollar basis. 

The Guaranteed Lifetime Withdrawal Benefit can only be taken as a withdrawal benefit and it does not increase the Policy Value. 

  

					
	NIC16 RGMB510616(IS)(NY)	  	(4)	  	(Income-Single)

 ARTICLE III CONTINUED 

WITHDRAWAL PERCENTAGE 
 The Withdrawal Percentage is used
to calculate the Rider Withdrawal Amount. The percentage is determined using the number of Rider Years and the attained age (age at last birthday) of the Annuitant at the time of the first withdrawal of any amount from the Policy Value taken on or
after the Rider Anniversary following the Annuitant’s attainment of the minimum benefit age. Once the Withdrawal Percentage is established, it may only be changed by an automatic step-up. Upon automatic step-up, the Withdrawal Percentage will
be reset based on using the number of Rider Years and the attained age of the Annuitant at the time of the automatic step-up. The Withdrawal Percentages are shown in the table on page 2 of this rider. 

If the Annuitant is not yet the minimum benefit age on the rider date, the Withdrawal Percentage will be zero until the Rider Anniversary following the
Annuitant’s birthday in which they attain the minimum benefit age. Withdrawals prior to age 59 1/2 may be subject to the IRS 10% early withdrawal penalty. 

RIDER WITHDRAWAL AMOUNT 
 The Rider Withdrawal Amount will
be equal to the greater of: 
  

	1)	The withdrawal percentage multiplied by the Withdrawal Base; or 

  

	2)	An amount equal to the minimum required distribution amount, if any. The minimum required distribution is calculated based on the rules established by the IRS. The minimum required distribution may only be used if all
of the following are true: 

  

	 	A)	the policy to which this rider is attached is a tax-qualified policy for which IRS minimum required distributions are required, 

  

	 	B)	the minimum required distributions do not start prior to the Annuitant’s attained age 70 1/2, 

  

	 	C)	the minimum required distributions are based on either the Uniform Lifetime table or the Joint Life and Last Survivor Expectancy table, 

 

	 	D)	the minimum required distributions are based on age of the living Annuitant. The minimum required distributions cannot be based on the age of someone who is deceased, 

 

	 	E)	the minimum required distributions are based only on the policy to which this rider is attached, and 

  

	 	F)	the minimum required distributions are only for the current Rider Year. Amounts carried over from past Rider Years are not considered. 

If any of the above are not true, then 2) is equal to zero and it is not available as a Rider Withdrawal Amount. 

If You withdraw less than the Rider Withdrawal Amount in a Rider Year, the unused portion cannot be carried over to the next Rider Year. 

Surrender charges may apply if Your Rider Withdrawal Amount exceeds Your surrender charge-free amount. 

WITHDRAWAL BASE 
 The Withdrawal Base is used to calculate
the Rider Withdrawal Amount and the Rider Fee. On the rider date, the Withdrawal Base is equal to the Policy Value (less any premium enhancements, if applicable to Your policy, if the rider is added in the first Policy Year). During any Rider Year,
the Withdrawal Base is increased by subsequent Premium Payments (not including premium enhancements, if applicable to Your policy), and is reduced for Excess Withdrawals. 

On each Rider Anniversary, the Withdrawal Base will be set to the greater of: 
  

	 	1)	The current Withdrawal Base; or 

  

	 	2)	The Policy Value on the Rider Anniversary. 

 AUTOMATIC STEP-UP FEATURE 

The rider receives an automatic step-up if the Withdrawal Base is equal to the Policy Value on the Rider Anniversary. This feature does not require the
termination of the existing rider. This rider will continue with the same rider date and features. The rider fee percentage and withdrawal percentage may be changed due to an automatic step-up. Beginning with the [first] Rider Anniversary, the rider
fee percentage may be increased if there is an automatic step-up, but will not exceed the maximum rider fee percentage described on page 1 of this rider. 

You have the right to reject an automatic step-up within [30] days following a Rider Anniversary, if the rider fee percentage increases. If You reject an
automatic step-up, You must notify us in a manner which is acceptable to us, however You are eligible for future automatic step-ups. Changes as a result of the automatic step-up feature will be reversed upon rejection. Any increase in the rider fee
percentage or withdrawal percentage will also be reversed. 

  

					
	NIC16 RGMB510616(IS)(NY)	  	(5)	  	(Income-Single)

 ARTICLE III CONTINUED 

WITHDRAWAL BASE ADJUSTMENTS 
 Gross Partial Withdrawals,
taken in a Rider Year, less than or equal to the Rider Withdrawal Amount will not reduce the Withdrawal Base. Excess Withdrawals will reduce the Withdrawal Base by the Withdrawal Base Adjustment which may be more than the dollar amount of the
Excess Withdrawal. The Withdrawal Base Adjustment is the greater of 1) and 2), where: 
  

	1)	is the Excess Withdrawal amount; and 

  

	2)	is the result of (A multiplied by B), divided by C, where: 

  

	 	A)	is the Excess Withdrawal amount; 

  

	 	B)	is the Withdrawal Base prior to the Excess Withdrawal; and 

  

	 	C)	is the Policy Value after the Rider Withdrawal Amount has been withdrawn, but prior to the withdrawal of the Excess Withdrawal amount. 

ISSUE AGE AND SURVIVAL 
 The benefits under this rider
depend on the Annuitant being alive at the time of withdrawal and the amount of the benefit depends on the attained age of the Annuitant. Reasonable proof of survival and the date of birth may be required by the Company. 

If the Annuitant’s age has been misstated, this rider’s fees and benefits will be adjusted to the amounts which would have been calculated for the
correct age. If withdrawals under the provisions of this rider have already commenced and the misstatement caused the Rider Withdrawal Amount to be overstated, any withdrawal in excess of the correct Rider Withdrawal Amount will be considered an
Excess Withdrawal and will impact the Withdrawal Base and Rider Withdrawal Amount. If overpayments occurred when the sum of the accumulated values in all the Investment Options was zero, the amount of that overpayment will be deducted from one or
more future payments until this amount is paid in full. 
 However, if this rider would not have been issued had the age not been misstated, You will lose
all of the benefits provided by this rider and any fees charged for this rider will be returned. Your current Policy Value will be re-allocated to Your current investment allocations for the Select Investment Options and Flexible Investment Options,
if any, as of the date we are notified of the misstatement of age. 
 ARTICLE IV 

CONTINUATION 
 In the case of spousal joint Owners where
one spouse is the Annuitant, if the spouse who is not the Annuitant dies and the surviving spouse is the sole beneficiary, the rider continues with the same rider values. In the case of spousal joint Owners where one spouse is the Annuitant, if the
spouse who is the Annuitant dies, this rider will terminate. 
 In the case of non-spousal joint Owners where an Owner who is not the Annuitant dies, the
surviving Owner (who is also the sole designated beneficiary) may elect to receive lifetime income payments under this rider instead of receiving any benefits applicable to the policy. The lifetime income payments must begin no later than 1 year
after the Owner’s death and will be equal to the rider withdrawal amount divided by the number of payments made per year. Once the payments begin, no additional Premium Payments will be accepted and no additional withdrawals will be paid. 

ANNUITIZATION 
 On the maximum Annuity Commencement Date,
as described in Your policy, You will have the option to receive lifetime income payments each year that are no less than Your Rider Withdrawal Amount. 

  

					
	NIC16 RGMB510616(IS)(NY)	  	(6)	  	(Income-Single)

 ARTICLE IV CONTINUED 

TERMINATION 
 This rider will terminate upon the earliest
of: 
  

	1)	the date the policy to which this rider is attached terminates; 

  

	2)	prior to Your Policy Value reaching zero, the date we receive, in Good Order, required information to process death claim for the Annuitant’s death; 

 

	3)	on or after Your Policy Value equals zero, and the Annuitant’s date of death; 

  

	4)	the date You elect to receive annuity payments under Your policy; and 

  

	5)	the date You notify us in writing of Your intention to terminate this rider (this date must be within [30] days after the [fifth] Rider Anniversary or any [fifth] Rider Anniversary thereafter). 

Termination of the rider will result in the loss of all benefits provided by the rider. After termination, Rider Fees will no longer be assessed and
rebalancing will be stopped. Upon termination, all Policy Value in the Stable Account will be transferred to the Money Market Subaccount available in Your policy and no additional Premium Payments will be allowed into the Stable Account. 

REPORTS TO OWNER 
 We will give You a report at least once
each Policy Year. Before You are eligible to receive the Rider Withdrawal Amount, the report will direct You to contact the Company for information regarding Your Rider Withdrawal Amount. After You are eligible for Your Rider Withdrawal Amount, this
amount will be included in the report. 
  

																	
		 	 Signed for us at our home office.

 
	  		 	

																					
		 	 	  	

	 	 	 		  		 	 	  	

	  		  	 	 	
		 		  	Jay Orlandi	 	 	 		  		 		  	Blake Bostwick	  		  	 	 	
		 		  	Secretary	 	 	 		  		 		  	President	  		  	 	 	
		 		  		 	 	 		  		 		  		  		  	 	 	
		 	 	  		 	 	 		  		 	 	  		  		  	 	 	

  

					
	NIC16 RGMB510616(IS)(NY)	  	(7)	  	(Income-Single)

 APPENDIX 

The following demonstrates, on a purely hypothetical basis, the rebalancing mechanics and quarterly fee calculations of this guaranteed lifetime withdrawal
benefit. The investment restrictions, rider fee percentages, and withdrawal percentages for Your rider may vary from the percentages used below. 

Rebalancing Examples 
 The following examples assume the
initial premium allocations listed in the table below, which we assume satisfy the premium investment requirements. 
  

									
	 Investment Option Allocations:
	  	Initial Premium
Allocations	 	  	Initial Premium
Allocation Percentages	 
	 Stable Account
	  	$	 20,000	  	  	 	20	% 
	 Select Investment Option Fund A
	  	$	13,000	  	  	 	13	% 
	 Select Investment Option Fund B
	  	$	13,000	  	  	 	13	% 
	 Select Investment Option Fund C
	  	$	4,000	  	  	 	4	% 
	 Total Select Investment Options
	  	$	30,000	  	  	 	30	% 
	 Flexible Investment Option Fund A
	  	$	14,000	  	  	 	14	% 
	 Flexible Investment Option Fund B
	  	$	14,000	  	  	 	14	% 
	 Flexible Investment Option Fund C
	  	$	22,000	  	  	 	22	% 
	 Total Flexible Investment Options
	  	$	50,000	  	  	 	50	% 
		  	  
	  
	 	  	  
	  
	 
	 Total Investments
	  	$	100,000	  	  	 	100	% 

 Example 1: Calculation at rider issue for the rebalance allocations: 

The Stable Account portion of the Policy Value is not included in the quarterly Rebalance, therefore the rebalancing allocation percentages are calculated by
multiplying the initial premium allocation percentages for the Select Investment Options and Flexible Investment Options by a ratio. The ratio is calculated by taking 100%, divided by 100% less the Stable Account premium allocation percentage. The
ratio for this example would be 100% / (100% - 20%) = 1.25. 
  

													
	 Investment Option Allocations:
	  	Initial Premium
Allocations	 	  	Initial Premium
Percentages	 	 	Unrounded
Rebalancing
Percentages	 
	 Stable Account
	  	$	20,000	  	  	 	20	% 	 	 	N/A	  
	 Total Select Investment Options
	  	$	30,000	  	  	 	30	% 	 	 	37.5	% 
	 Total Flexible Investment Options
	  	$	50,000	  	  	 	50	% 	 	 	62.5	% 
		  	  
	  
	 	  	  
	  
	 	 	  
	  
	 
	 Total Investments
	  	$	100,000	  	  	 	100	% 	 	 	100.0	% 

 Whole percentages are required for the rebalancing percentages and must sum up to equal 100%. To satisfy this requirement and
ensure the rebalance allocation requirement is met for each of the investment options, the sum of the Select Investment Options rebalancing percentage is rounded to the nearest whole percent (hereafter referred to as Select Rebalance Total) but no
less than the minimum allocation for rebalance. The Select Rebalance Total is deducted from 100% to get the total Flexible Investment Options rebalancing percentage (hereafter referred to as Flexible Rebalance Total). The Select Rebalance Total and
Flexible Rebalance Total percentages are the end result which will be achieved by the quarterly Rebalance. 
 Table 1 

 

									
	 	  	Unrounded
Rebalancing	 	 	Rounded
Rebalancing	 
	 Investment Option Allocations:
	  	Percentages	 	 	Percentages	 
	 Stable Account
	  	 	N/A	  	 	 	N/A	  
	 Total Select Investment Options
	  	 	37.5	% 	 	 	38	% 
	 Total Flexible Investment Options
	  	 	62.5	% 	 	 	62	% 
		  	  
	  
	 	 	  
	  
	 
	 Total Investments
	  	 	100.0	% 	 	 	100	% 

  

					
	NIC16 RGMB510616(IS)(NY)	  	(A-1)	  	(Income-Single)

 APPENDIX 
 We
apply the same ratio and rounding to each individual investment option chosen and sum up the total Select and total Flexible Investment Options separately. The totals are compared to Select Rebalance Total and Flexible Rebalance Total to determine
where any adjustments need to be made. In the example below, adjustments will need to be made to the Select Investment Options to bring the total percentage up to 38% and the Flexible Investment Options down to 62%, per the result from Table 1.

 Table 2 
  

													
	 	  	 	 	  	 	 	 	Pre-Adjusted	 
	 	  	Initial Premium	 	  	Initial Premium	 	 	Rebalancing	 
	 Investment Option Allocations:
	  	Allocations	 	  	Percentages	 	 	Percentages	 
	 Stable Account
	  	$	 20,000	  	  	 	20	% 	 	 	N/A	  
	 Select Investment Option Fund A
	  	$	13,000	  	  	 	13	% 	 	 	16	% 
	 Select Investment Option Fund B
	  	$	13,000	  	  	 	13	% 	 	 	16	% 
	 Select Investment Option Fund C
	  	$	4,000	  	  	 	4	% 	 	 	5	% 
	 Total Select Investment Options
	  	$	30,000	  	  	 	30	% 	 	 	37	% 
	 Flexible Investment Option Fund A
	  	$	14,000	  	  	 	14	% 	 	 	18	% 
	 Flexible Investment Option Fund B
	  	$	14,000	  	  	 	14	% 	 	 	18	% 
	 Flexible Investment Option Fund C
	  	$	22,000	  	  	 	22	% 	 	 	28	% 
	 Total Flexible Investment Options
	  	$	50,000	  	  	 	50	% 	 	 	64	% 
		  	  
	  
	 	  	  
	  
	 	 	  
	  
	 
	 Total Investments
	  	$	100,000	  	  	 	100	% 	 	 	101	% 

 To get the total Select Investment Options rebalancing percent to equal 38%, we must add 1% to one of the funds. Any
adjustments will first be made equally to the fund(s) with the greatest allocation. If there are multiple funds with the greatest allocation and the adjustments cannot be divided equally, we will adjust in alphabetical order the fund(s) with the
greatest allocation. In the example below, we made the adjustment to the Select Investment Option Fund A. 
 To get the total Flexible Investment Options
rebalancing percent to 62%, we must subtract 2% from one or more funds. Since there is only one fund with the greatest allocation, we have made the adjustment to the Flexible Investment Option Fund C 

Table 3 
  

									
	 Investment Option Allocations:
	  	Pre-Adjusted Rebalancing
Percentages	 	 	Rebalancing
Percentages	 
	 Stable Account
	  	 	N/A	  	 	 	N/A	  
	 Select Investment Option Fund A
	  	 	16	% 	 	 	17	% 
	 Select Investment Option Fund B
	  	 	16	% 	 	 	16	% 
	 Select Investment Option Fund C
	  	 	5	% 	 	 	5	% 
	 Total Select Investment Options
	  	 	37	% 	 	 	38	% 
	 Flexible Investment Option Fund A
	  	 	18	% 	 	 	18	% 
	 Flexible Investment Option Fund B
	  	 	18	% 	 	 	18	% 
	 Flexible Investment Option Fund C
	  	 	28	% 	 	 	26	% 
	 Total Flexible Investment Options
	  	 	64	% 	 	 	62	% 
		  	  
	  
	 	 	  
	  
	 
	 Total Investments
	  	 	101	% 	 	 	100	% 

 Example 2: Calculation for first quarter Rebalance: 

At the end of the first Rider Quarter, assume that the investment options have the following values: 

Table 4 
  

									
	 	  	 	 	  	Allocation Percentage	 
	 Investment Option Allocations:
	  	Allocation Amounts
Prior to Rebalance	 	  	of Rebalancing Funds
Prior to Rebalance	 
	 Stable Account
	  	$	20,050	  	  	 	N/A	  
	 Select Investment Option Fund A
	  	$	13,090	  	  	 	17	% 
	 Select Investment Option Fund B
	  	$	11,550	  	  	 	15	% 
	 Select Investment Option Fund C
	  	$	3,850	  	  	 	5	% 
	 Total Select Investment Options
	  	$	28,490	  	  	 	37	% 
	 Flexible Investment Option Fund A
	  	$	13,090	  	  	 	17	% 
	 Flexible Investment Option Fund B
	  	$	14,630	  	  	 	19	% 
	 Flexible Investment Option Fund C
	  	$	20,790	  	  	 	27	% 
	 Total Flexible Investment Options
	  	$	48,510	  	  	 	63	% 
		  	  
	  
	 	  	  
	  
	 
	 Total Investments
	  	$	97,050	  	  	 	100	% 

  

  

					
	NIC16 RGMB510616(IS)(NY)	  	(A-2)	  	(Income-Single)

 APPENDIX 

The result of the Rebalance back to the rebalancing percentages from Table 3 is: 
  

													
	 Table 5
  
	  	 	 	  	 	 	 	 	 
	 	  	 	 	  	Allocation Percentage	 	 	Allocation Percentage	 
	 Investment Option Allocations:
	  	Allocation Amounts
After Rebalancing	 	  	of Rebalancing Funds
After Rebalance	 	 	of Policy Value
After Rebalance	 
	 Stable Account
	  	$	20,050	  	  	 	N/A	  	 	 	21	% 
	 Select Investment Option Fund A
	  	$	13,090	  	  	 	17	% 	 	 	13	% 
	 Select Investment Option Fund B
	  	$	12,320	  	  	 	16	% 	 	 	13	% 
	 Select Investment Option Fund C
	  	$	3,850	  	  	 	5	% 	 	 	4	% 
	 Total Select Investment Options
	  	$	29,260	  	  	 	38	% 	 	 	30	% 
	 Flexible Investment Option Fund A
	  	$	13,860	  	  	 	18	% 	 	 	14	% 
	 Flexible Investment Option Fund B
	  	$	13,860	  	  	 	18	% 	 	 	14	% 
	 Flexible Investment Option Fund C
	  	$	20,020	  	  	 	26	% 	 	 	21	% 
	 Total Flexible Investment Options
	  	$	47,740	  	  	 	62	% 	 	 	49	% 
		  	  
	  
	 	  	  
	  
	 	 	  
	  
	 
	 Total Investments
	  	$	97,050	  	  	 	100	% 	 	 	100	% 

 This rebalancing process will continue on a quarterly basis while this rider is in force. 

Rider Fee Calculation Examples 
 The quarterly fee
is calculated as follows: 
 Multiply (1) by (2) by (3), where: 
  

	1)	is Withdrawal Base 

  

	2)	is rider fee percentage 

  

	3)	is number of days in the Rider Quarter divided by the number of days within the applicable Rider Year 

 The fee
adjustment for additional Premium Payments and Excess Withdrawals is calculated as follows: Multiply (1) by (2) by (3), where: 
  

	1)	is Withdrawal Base change (i.e. Withdrawal Base after the transaction minus the Withdrawal Base before the transaction) 

  

	2)	is rider fee percentage 

  

	3)	is number of days remaining in the Rider Quarter divided by the number of days within the applicable Rider Year 

The following two examples use assumed fees and values. The assumed Rider Year is not a leap year. 

Example 1: Calculation at rider issue for first quarter fee assuming an initial Withdrawal Base of $100,000 and an initial fee percentage of 1.50%.

 = 100,000 * 0.0150 * (91/365) 
 = 1,500 * (91/365) 

= $373.97 
 Example 2: Calculation for first quarter fee
assuming initial Withdrawal Base from Example 1 above, plus adjustment for additional Premium Payment of $10,000 made with 20 days remaining in the first Rider Quarter. The Withdrawal Base change and total transaction amount equal $10,000. 

Fee adjustment as follows: 
 = 10,000 * 0.0150 * (20/365) 

= 150 * (20/365) 
 = $8.22 

  

					
	NIC16 RGMB510616(IS)(NY)	  	(A-3)	  	(Income-Single)

 APPENDIX 

Rider Fee Calculation Examples continued 
 Total fee
assessed at end of first Rider Quarter (assuming no further Rider Fee adjustments): 
 = 8.22 + 373.97 

= $382.19 
 The following two examples use assumed fees and
values. The assumed Rider Year is not a leap year. 
 Example 3: Calculation for second quarter fee at beginning of second Rider Quarter, assuming
Withdrawal Base of $110,000 and a fee percentage of 1.50%. 
 = 110,000 * 0.0150 * (91/365) 

= 1,650 * (91/365) 
 = $411.37 

Example 4: Calculation for second quarter fee assuming beginning values as in Example 3 above, plus adjustment for Gross Partial Withdrawal of $10,000
taken with 40 days remaining in the second Rider Quarter. Assumes withdrawal percentage of 5%, Policy Value of $93,500 prior to the transaction and change in Withdrawal Base as follows: 

Rider Withdrawal Amount (RWA) = Withdrawal Base * Withdrawal Percentage = $110,000 * .05 = $5,500 

Excess Withdrawal = Difference between Gross Partial Withdrawal and RWA = $10,000 - $5,500 = $4,500 

Withdrawal Base Adjustment = Max (Excess Withdrawal, Excess Withdrawal * Withdrawal Base prior to withdrawal / Policy Value after RWA has been withdrawn but
before Excess Withdrawal) = Max [$4,500, $4,500 * $110,000 / ($93,500-$5,500)] = Max ($4,500, $5,625) = $5,625 
 Fee adjustment as follows: 

= -5,625 * 0.0150 * (40/365) 
 = -84.38 * (40/365) 

= $-9.25 
 Total fee assessed at end of second Rider Quarter
(assuming no further Rider Fee adjustments): 
 = 411.37 – 9.25 

= $402.12 
 The new Withdrawal Base = $110,000 - $5,625 =
$104,375 

  

					
	NIC16 RGMB510616(IS)(NY)	  	(A-4)	  	(Income-Single)

							
	

	  		  	Home Office located at:	  	
	  	 	  	440 Mamaroneck Avenue, Harrison, New York 10528	  	 
	  		  		  	
	  		  	Adm. Office located at:	  	
	  	 	  	4333 Edgewood Road N.E. Cedar Rapids, Iowa 52499	  	 
	  		  	(319) 355-8511	  	 
	  		  	www.transamerica.com	  	 
	    A Stock Company (Hereafter called the Company, we, our or us)	  	 	  		  	 

 GUARANTEED LIFETIME WITHDRAWAL BENEFIT 

This rider is issued as a part of the policy to which it is attached. All provisions of the policy that do not conflict with this rider apply to this rider.
In the event of any conflict between the provisions of this rider and the provisions of the policy, the provisions of this rider shall prevail over the provisions of the policy. 

The purpose of this guaranteed living benefit provided under this annuity rider is to provide a stream of income payments to the Owner. 

You may cancel this rider on or before midnight of the thirtieth calendar day after You receive it and no Rider Fees will be assessed. Upon cancellation,
all Policy Value in the Stable Account will be transferred to the Money Market Subaccount available in Your policy. 
 This rider provides a minimum
withdrawal benefit that guarantees, upon election, a series of withdrawals from the policy equal to the Withdrawal Percentage shown below applied to the Withdrawal Base. The Withdrawal Base is established for the sole purpose of determining the
minimum withdrawal benefit and is not used in calculating the cash surrender value or other guaranteed benefits. 
  

																																													
	 RIDER DATA SPECIFICATION
	   
	 	
		  		  				 		  				  		  				 		  				  		  				 		  				  		  				 	
	 Policy Number:    
	  	 	  	 	12345	  	 	 	  				  		  				 		  				  		  				 		  				  		  				 	
	 Rider Date:    
	  		  	 	08/01/2016	  	 	 	  				  		  				 		  				  		  				 		  				  		  				 	
	 Initial Rider Fee Percentage*:    
	  	 	  	 	1.50	  	 	 	  				  		  				 		  				  		  				 		  				  		  				 	
		  	Required Allocations
		  	Premium	  				  	Rebalance
		  		  	 	Minimum	  	 		  				  		  	 	Maximum	  	 		  				  		  	 	Minimum	  	 		  				  		  	 	Maximum	  	 	
	 Stable Account:    
	  	 	  	 	20%	  	 	 	  				  	 	  	 	20%	  	 	 	  				  		  	 	N/A	  	 		  				  		  	 	N/A	  	 	
	 Select Investment Options:    
	  		  	 	20%	  	 	 	  				  		  	 	80%	  	 	 	  				  	 	  	 	25%	  	 	 	  				  	 	  	 	100%	  	 	 
	 Flexible Investment Options:    
	  	 	  	 	0%	  	 	 	  				  	 	  	 	60%	  	 	 	  				  	 	  	 	0%	  	 	 	  				  	 	  	 	75%	  	 	 
		  			 		  				  		  				 		  				  		  				 		  				  		  				 	
	 Guaranteed Minimum Effective Annual Interest
Rate    
 for Stable Account:    
	  	[1.00%]	  	 		  				  		  				 		  				  		  				 		  				  		  				 	
		  			 		  				  		  				 		  				  		  				 		  				  		  				 	
	 Annuitant:    
	  	[John Doe]	  	 		  				  		  				 		  				  		  				 		  				  		  				 	
	 Annuitant’s Issue Age/Sex:    
	  	[65 / Male]	  	 		  				  		  				 		  				  		  				 		  				  		  				 	
		  			 		  				  		  				 		  				  		  				 		  				  		  				 	
	 Annuitant’s Spouse:    
	  	[Jane Doe]	  	 		  				  		  				 		  				  		  				 		  				  		  				 	
	 Annuitant’s Spouse’s Issue
Age/Sex:    
	  	[65 / Female]	  	 		  				  		  				 		  				  		  				 		  				  		  				 	
		  			 		  				  		  				 		  				  		  				 		  				  		  				 	
	 Minimum Benefit Age:    
	  	[59]	  	 		  				  		  				 		  				  		  				 		  				  		  				 	

  

	*	The initial rider fee percentage is for the life of the rider, provided there are no automatic step-ups. When an automatic step-up occurs, the rider fee percentage will never be increased by more than [0.75%] greater
than the initial rider fee percentage shown above. Therefore, the maximum rider fee percentage will never be greater than the initial rider fee percentage, plus [0.75%]. 

Guaranteed Lifetime Withdrawal Benefit: The withdrawal percentage is used to determine the Rider Withdrawal Amount as described in Article III of this
rider. The withdrawal percentages are shown in the table below. 

  

					
	NIC16 RGMB510616(IJ)(NY)	  	(1)	  	(Income-Joint)

																													
	Withdrawal Percentage
		 		 		 		 		 		  		  		  		 		  		  		  		 		  	
		 	 Attained Age
	 		 		 		 	[Rider Years 1-5]	  		  		  		 	[Rider Years 6-10]	  		  		  		 	[Rider Years 11+]	  	
	 	 	 59-64
	 	 	 		 	 	 	3.5%	  	 	  		  	 	 	4.5%	  	 	  		  	 	 	5.5%	  	 
	 	 	 65-79
	 	 	 		 		 	4.5%	  	 	  		  		 	5.5%	  	 	  		  		 	6.5%	  	 
	 	 	 80+
	 	 	 		 	 	 	5.5%	  	 	  		  	 	 	6.5%	  	 	  		  	 	 	7.5%	  	 

 ARTICLE I 

DEFINITIONS: 
 Terms used that are not defined in this
rider shall have the same meaning as those in Your policy. 
 Excess Withdrawal 

The excess of a Gross Partial Withdrawal over the Rider Withdrawal Amount remaining prior to the withdrawal, if any. 

Flexible Investment Options 
 A designated group of
Investment Options identified by us to which You must allocate a portion of Your Premium Payments and Policy Value as shown on page 1 of this rider and as described in Article II. You will be notified if there are changes made to the Investment
Options within the designated group. 
 Gross Partial Withdrawal 

The amount that will be deducted from Your Policy Value as a result of each partial withdrawal. 

Rider Anniversary 
 The anniversary of the rider date.

 Rider Fee 
 The fees charged for the benefits under
this rider. 
 Rider Quarter 
 Each successive
three-month period beginning on the rider date. 
 Rider Quarterversary 

For each Rider Quarter, the same day of the month as the rider date, or the next business day if our Administrative Office or the New York Stock Exchange is
closed. If a certain date does not exist in a given month, the first day of the following month will be used. 
 Rider Withdrawal Amount 

The maximum amount that can be withdrawn from the policy each Rider Year without causing an Excess Withdrawal under the terms of this rider and thus reducing
the Withdrawal Base. This amount will change if the Withdrawal Base or Withdrawal Percentage changes. 
 Rider Year 

Each twelve-month period following the rider date. 
 Stable
Account 
 The Stable Account is a Fixed Account Option under Your policy, only available if You elect this rider, to which You must allocate a portion
of Your Premium Payments and Policy Value shown on page 1 of this rider. Allocations applied to the Stable Account will be credited interest based on a fixed rate. The interest rates will be credited for increments of at least one year measured from
each Premium Payment date and will automatically renew and remain in the Stable Account. These rates will never be less than the Guaranteed Minimum Effective Annual Interest Rate for Stable Account shown on page 1 of this rider. 

  

					
	NIC16 RGMB510616(IJ)(NY)	  	(2)	  	(Income-Joint)

 ARTICLE I CONTINUED 

Select Investment Options 
 A designated group of
Investment Options identified by us to which You must allocate a portion of Your Premium Payments and Policy Value shown on page 1 of this rider and as described in Article II. You will be notified if there are changes made to the Investment Options
within the designated group. 
 Withdrawal Base 

The amount used to calculate the Rider Withdrawal Amount and the Rider Fee. This amount has no cash value and cannot be taken as a lump sum. 

ARTICLE II 
 REQUIRED ALLOCATIONS 

If You elect this rider, a certain percentage of Your Policy Value on the rider date must be allocated to the Stable Account, the Select Investment Options and
the Flexible Investment Options, as specified for premiums in the Required Allocations shown on page 1, in the Rider Data Specification section. Any transfers to and from the Select Investment Options and Flexible Investment Options will be
validated using the prior day’s Policy Values to ensure compliance as specified for rebalancing in the Required Allocations shown on page 1, in the Rider Data Specification section, at the time of the request. Changes in Policy Values due to
market movements on other dates will not be treated as a violation of the Required Allocations. After the rider date, the allocation of all Premium Payments made (and any Premium Enhancements, if applicable to Your policy) must also comply with the
Required Allocations, so long as this rider is effective. No further change or limitation of the available investment options will be made without prior approval of the New York Department of Financial Services. 

Transfers to and from the Stable Account are not permitted. Withdrawals from the Stable Account are not permitted until all other Investment Options are
depleted of value. Withdrawals from the Flexible Investment Options and Select Investment Options will be deducted on a pro-rata basis. If You do not wish to maintain the Required Allocations shown on page 1, in the Rider Data Specification section,
this rider must be terminated, subject to the restrictions and requirements as described in Article IV, prior to making any transfer. 
 Enrollment in
Dollar Cost Averaging is not available while this rider is in effect. 
 REBALANCING 

While this rider is effective, quarterly Rebalancing is required and will take place at the end of each successive Rider Quarter on the same date Your Rider
Fee is deducted. If the day Rebalancing takes place is not a Market Day, the value of accumulation units redeemed or purchased due to Rebalancing will be determined as of the next Market Day. We will automatically transfer amounts among Subaccounts
according to the most recent rebalancing allocation instructions on file that comply with the Required Allocations for Rebalancing as shown on page 1, in the Rider Data Specification section. On the rider date, Your rebalancing allocation
instructions will be established by applying a ratio of Your current investment allocation instructions for new premium. Because the Stable Account is not included in the quarterly rebalancing process and whole percentages are required, it may be
necessary for the company to make adjustments (positive or negative) to the calculated rebalance allocation percentages to accommodate for rounding to the nearest whole percent. Adjustments needed will be applied to the Select Investment Options and
Flexible Investment Options individually to ensure the requirements for each designated group are met. Any adjustments will first be made to the Subaccount with the greatest percentage allocation. If more than one Subaccount has the greatest
percentage allocation, the adjustment will be divided equally among those Subaccounts with the greatest percentage allocation. If the adjustment cannot be divided equally, we will make adjustments in alphabetical order to the Subaccount(s) with the
greatest percentage allocation. You will be notified in writing of the calculated rebalance allocation percentages prior to the first quarter Rebalancing. You may request changes to Your rebalancing allocation instructions while this rider remains
effective as long as they comply with the required rebalance allocations. Rebalancing will not cease upon the request of any transfer. 
 Please see the
Appendix attached to this rider which illustrates the initial calculation of rebalancing allocation percentages as well as the rebalancing process. 

RIDER FEE 
 The Rider Fee is deducted on each successive
Rider Quarterversary, on the same day of the month as the rider date. If a day does not exist in a given month, the first day of the following month will be used. If a Rider Fee is deducted from the Flexible Investment Options and Select Investment
Options on a day which is not a Market Day, the value of accumulation units redeemed will be determined as of the next Market Day. The Rider Fee is calculated and stored at issue and at each subsequent Rider Quarterversary for the upcoming Rider
Quarter. 
  

  

					
	NIC16 RGMB510616(IJ)(NY)	  	(3)	  	(Income-Joint)

 ARTICLE II CONTINUED 

It will be deducted automatically from Flexible Investment Options and Select Investment Options, on a pro rata basis, on each Rider Quarterversary. The
initial rider fee percentage is shown and the maximum rider fee percentage is described on page 1, in the Rider Data Specification section. The rider fee percentage will not change during the first Rider Year, and will only change thereafter due to
an automatic step-up. You will be notified of any increase in the rider fee percentage. If this rider is terminated prior to the end of a Rider Quarter, a portion of the fee will also be deducted based on the number of days that have elapsed since
the end of the previous Rider Quarterversary. 
 The quarterly Rider Fee is calculated as follows: 

Multiply (1) by (2) by (3), where: 
  

	1)	is Withdrawal Base; 

  

	2)	is rider fee percentage; 

  

	3)	is number of days in the Rider Quarter divided by the number of days within the applicable Rider Year. 

 The
fee will be adjusted if the Withdrawal Base is adjusted during the Rider Quarter. The fee adjustments are calculated as follows: 
 Multiply (1) by
(2) by (3), where: 
  

	1)	is the change in Withdrawal Base; 

  

	2)	is rider fee percentage; 

  

	3)	is number of days remaining in the Rider Quarter divided by the number of days within the applicable Rider Year. 

Please see the Appendix attached to this rider which illustrates how the Rider Fee is calculated. 

ARTICLE III 
 GUARANTEED LIFETIME WITHDRAWAL
BENEFIT 
 Under this rider, we guarantee that You can receive up to the Rider Withdrawal Amount each Rider Year, regardless of the Policy Value, (first
as withdrawals from Your Policy Value and, if necessary, as payments from us) until the Annuitant’s or the Annuitant’s spouse’s death, whichever is later. The Annuitant’s spouse as of the rider date is hereafter referred to as
the Annuitant’s spouse. As it pertains to the benefits of this rider, the Annuitant’s spouse cannot be changed. The Annuitant’s spouse must be the sole primary beneficiary and/or a joint Owner on the policy to which this rider is
attached. The only living Owners allowed on the policy to which this rider is attached are the Annuitant and the Annuitant’s spouse. This rider requires the Annuitant to also be an Owner, except in the case of non-natural Owners. Such
non-natural Owners must be established for the benefit of the Annuitant. Once this rider is issued the Annuitant cannot be changed, except when the underlying Individual Retirement Annuity (IRA) policy is transferred pursuant to a divorce, or a
surviving spouse continues the policy pursuant to the Continuation provision in Article IV. In the event of a divorce, this rider will continue during the life of the Annuitant provided the Annuitant remains an Owner. Upon divorce, the Annuitant and
former spouse may also mutually agree to remove the former spouse as joint Owner or primary beneficiary and by doing so will forfeit any benefits for the former spouse. 

Withdrawals will reduce the Policy Value and death benefit of the policy to which this rider is attached. If the Policy Value equals zero, You cannot make
subsequent Premium Payments and all other policy features, benefits and guarantees are no longer available. Also, if the Policy Value equals zero and the rider remains inforce, we will, unless instructed otherwise, make payments using the current
payment instructions on file with us equal to the Rider Withdrawal Amount divided by the frequency of payments. If the younger of the Annuitant or Annuitant’s spouse has attained the minimum benefit age and a systematic payout option is not
active at the time the Policy Value equals zero, a monthly payment will begin. If the minimum benefit age has not been attained, the monthly payment will begin on the Rider Anniversary following the attainment of the minimum benefit age. Once the
payment amount and frequency are established, they cannot be changed and no additional withdrawals will be allowed. We have the right to reasonably require satisfactory evidence a person is alive if payment is based on that person being alive. 

While this rider is in-force, we will not invoke the Involuntary Cashout provision of the policy to which this rider is attached if this rider has a
Withdrawal Base of $2,000 or greater. 
  

  

					
	NIC16 RGMB510616(IJ)(NY)	  	(4)	  	(Income-Joint)

 ARTICLE III CONTINUED 

We guarantee that you may withdraw up to the rider withdrawal amount each year regardless of the policy value until the Annuitant’s or Annuitant’s
spouse’s death, whichever is later. 
 Example 

Assume the younger of the annuitant and the annuitant’s spouse is 65 and withdrawals begin and your Withdrawal Base is $100,000. Assuming
a withdrawal percentage of 4.50%, you could withdraw up to $4,500 during Rider Years 1 - 5 until the annuitant’s or the annuitant’s spouse’s death, which ever is later (assuming that you do not withdraw more than $4,500 during those
Rider Years). 
 Any amount you withdraw in excess of the rider withdrawal amount may impact the withdrawal base on a greater than dollar-for-dollar basis.

 The Guaranteed Lifetime Withdrawal Benefit can only be taken as a withdrawal benefit and it does not increase the policy value. 

WITHDRAWAL PERCENTAGE 
 The Withdrawal Percentage is used
to calculate the Rider Withdrawal Amount. The percentage is determined using the number of Rider Years and the attained age (age at last birthday) of the younger of the living spouses at the time of the first withdrawal of any amount from the Policy
Value taken on or after the Rider Anniversary following the younger of the living spouse’s attainment of the minimum benefit age. Once the Withdrawal Percentage is established, it may only be changed by an automatic step-up. Upon automatic
step-up, the Withdrawal Percentage will be reset based on using the number of Rider Years and the attained age of the younger of the living spouses at the time of the automatic step-up. The Withdrawal Percentages are shown in the table on page 2 of
this rider. 
 If the younger of the Annuitant and the Annuitant’s spouse is not yet the minimum benefit age on the rider date, the Withdrawal
Percentage will be zero until the Rider Anniversary following the younger of the living spouse’s birthday in which they attain the minimum benefit age. Withdrawals prior to age 59 1/2 may be subject to the IRS 10% early withdrawal penalty. 

RIDER WITHDRAWAL AMOUNT 
 The Rider Withdrawal Amount will
be equal to the greater of: 
  

	1)	The withdrawal percentage multiplied by the Withdrawal Base; or 

  

	2)	An amount equal to the minimum required distribution amount, if any. The minimum required distribution is calculated based on the rules established by the IRS. The minimum required distribution may only be used if all
of the following are true: 

  

	 	A)	the policy to which this rider is attached is a tax-qualified policy for which IRS minimum required distributions are required, 

  

	 	B)	the minimum required distributions do not start prior to the Annuitant’s attained age 70 1/2, 

  

	 	C)	the minimum required distributions are based on either the Uniform Lifetime table or the Joint Life and Last Survivor Expectancy table, 

 

	 	D)	the minimum required distributions are based on age of the living Annuitant or the Annuitant’s spouse if the Annuitant is deceased. The minimum required distributions cannot be based on the age of someone who is
deceased, 

  

	 	E)	the minimum required distributions are based only on the policy to which this rider is attached, and 

  

	 	F)	the minimum required distributions are only for the current Rider Year. Amounts carried over from past Rider Years are not considered. 

If any of the above are not true, then 2) is equal to zero and it is not available as a Rider Withdrawal Amount. 

If You withdraw less than the Rider Withdrawal Amount in a Rider Year, the unused portion cannot be carried over to the next Rider Year. 

Surrender charges may apply if Your Rider Withdrawal Amount exceeds Your surrender charge-free amount. 

 

  

					
	NIC16 RGMB510616(IJ)(NY)	  	(5)	  	(Income-Joint)

 ARTICLE III CONTINUED 

WITHDRAWAL BASE 
 The Withdrawal Base is used to calculate
the Rider Withdrawal Amount and the Rider Fee. On the rider date, the Withdrawal Base is equal to the Policy Value (less any premium enhancements, if applicable to Your policy, if the rider is added in the first Policy Year). During any Rider Year,
the Withdrawal Base is increased by subsequent Premium Payments (not including premium enhancements, if applicable to Your policy), and is reduced for Excess Withdrawals. 

On each Rider Anniversary, the Withdrawal Base will be set to the greater of: 
  

	1)	The current Withdrawal Base; or 

  

	2)	The Policy Value on the Rider Anniversary. 

 AUTOMATIC STEP-UP FEATURE 

The rider receives an automatic step-up if the Withdrawal Base is equal to the Policy Value on the Rider Anniversary. This feature does not require the
termination of the existing rider. This rider will continue with the same rider date and features. The rider fee percentage and withdrawal percentage may be changed due to an automatic step-up. Beginning with the [first] Rider Anniversary, the rider
fee percentage may be increased if there is an automatic step-up, but will not exceed the maximum rider fee percentage described on page 1 of this rider. 

You have the right to reject an automatic step-up within [30] days following a Rider Anniversary, if the rider fee percentage increases. If You reject an
automatic step-up, You must notify us in a manner which is acceptable to us, however You are eligible for future automatic step-ups. Changes as a result of the automatic step-up feature will be reversed upon rejection. Any increase in the rider fee
percentage or withdrawal percentage will also be reversed. 
 WITHDRAWAL BASE ADJUSTMENTS 

Gross Partial Withdrawals, taken in a Rider Year, less than or equal to the Rider Withdrawal Amount will not reduce the Withdrawal Base. Excess Withdrawals
will reduce the Withdrawal Base by the Withdrawal Base Adjustment which may be more than the dollar amount of the Excess Withdrawal. The Withdrawal Base Adjustment is the greater of 1) and 2), where: 

 

	1)	is the Excess Withdrawal amount; and 

  

	2)	is the result of (A multiplied by B), divided by C, where: 

  

	 	A)	is the Excess Withdrawal amount; 

  

	 	B)	is the Withdrawal Base prior to the Excess Withdrawal; and 

  

	 	C)	is the Policy Value after the Rider Withdrawal Amount has been withdrawn, but prior to the withdrawal of the Excess Withdrawal amount. 

 
 ISSUE AGE AND SURVIVAL 

The benefits under this rider depend on the Annuitant or Annuitant’s spouse being alive at the time of withdrawal and the amount of the benefit depends on
the attained age of the Annuitant and Annuitant’s spouse. Reasonable proof of survival and the date of birth may be required by the Company 
 If the
younger of the spouses’ ages has been misstated, this rider’s fees and benefits will be adjusted to the amounts which would have been calculated for the correct age. If withdrawals under the provisions of this rider have already commenced
and the misstatement caused the Rider Withdrawal Amount to be overstated, any withdrawal in excess of the correct Rider Withdrawal Amount will be considered an Excess Withdrawal and will impact the Withdrawal Base and Rider Withdrawal Amount. If
overpayments occurred when the sum of the accumulated values in all the Investment Options was zero, the amount of that overpayment will be deducted from one or more future payments until this amount is paid in full. 

However, if this rider would not have been issued had the age not been misstated, You will lose all of the benefits provided by this rider and any fees
charged for this rider will be returned. Your current Policy Value will be re-allocated to Your current investment allocations for the Select Investment Options and Flexible Investment Options, if any, as of the date we are notified of the
misstatement of age. 
  

  

					
	NIC16 RGMB510616(IJ)(NY)	  	(6)	  	(Income-Joint)

 ARTICLE IV 

CONTINUATION 
 In the case of spousal joint Owners where
one spouse is the Annuitant, if the spouse who is not the Annuitant dies and the surviving spouse is the sole beneficiary, the rider continues with the same rider values if the policy to which this rider is attached is continued until the death of
the surviving spouse. In the case of spousal joint Owners where one spouse is the Annuitant, if the spouse who is the Annuitant dies and the surviving spouse is the sole beneficiary, the rider continues with the same rider values if the policy to
which this rider is attached is continued until the death of the surviving spouse. 
 In the case of a single Owner where the spouse is the sole primary
beneficiary and on the death of the Owner the spouse continues the policy to which this rider is attached, the rider continues with the same rider values. 

ANNUITIZATION 
 On the maximum Annuity Commencement Date,
as described in Your policy, You will have the option to receive lifetime income payments each year that are no less than Your Rider Withdrawal Amount. 

TERMINATION 
 This rider will terminate upon the earliest
of: 
  

	1)	the date the policy to which this rider is attached terminates; 

  

	2)	prior to Your Policy Value reaching zero, the date we receive, in Good Order, required information to process death claim upon the later of Annuitant’s or Annuitant’s spouse’s death; 

 

	3)	on or after Your Policy Value equals zero, and the later of the Annuitant’s or Annuitant’s Spouse’s date of death; 

  

	4)	the date You elect to receive annuity payments under Your policy; and 

  

	5)	the date You notify us in writing of Your intention to terminate this rider (this date must be within [30] days after the [fifth] Rider Anniversary or any [fifth] Rider Anniversary thereafter). 

Termination of the rider will result in the loss of all benefits provided by the rider. After termination, Rider Fees will no longer be assessed and
rebalancing will be stopped. Upon termination, all Policy Value in the Stable Account will be transferred to the Money Market Subaccount available in Your policy and no additional Premium Payments will be allowed into the Stable Account. 

REPORTS TO OWNER 
 We will give You a report at least once
each Policy Year. Before You are eligible to receive the Rider Withdrawal Amount, the report will direct You to contact the Company for information regarding Your Rider Withdrawal Amount. After You are eligible for Your Rider Withdrawal Amount, this
amount will be included in the report. 
  

					
		  	Signed for us at our home office.	  	

  

																					
		 	 	  	

	 	 	 		  		 	 	  	

	  		  	 	 	
		 		  	Jay Orlandi	 	 	 		  		 		  	Blake Bostwick	  		  	 	 	
		 		  	Secretary	 	 	 		  		 		  	President	  		  	 	 	
		 		  		 	 	 		  		 		  		  		  	 	 	
		 	 	  		 	 	 		  		 	 	  		  		  	 	 	

  

					
	NIC16 RGMB510616(IJ)(NY)	  	(7)	  	(Income-Joint)

 APPENDIX 

The following demonstrates, on a purely hypothetical basis, the rebalancing mechanics and quarterly fee calculations of this guaranteed lifetime withdrawal
benefit. The investment restrictions, rider fee percentages, and withdrawal percentages for Your rider may vary from the percentages used below. 

Rebalancing Examples 
 The following examples assume the
initial premium allocations listed in the table below, which we assume satisfy the premium investment requirements. 
  

									
	 Investment Option Allocations:
	  	Initial Premium
Allocations	 	  	Initial Premium
Allocation Percentages	 
	 Stable Account
	  	$	 20,000	  	  	 	20	% 
	 Select Investment Option Fund A
	  	$	13,000	  	  	 	13	% 
	 Select Investment Option Fund B
	  	$	13,000	  	  	 	13	% 
	 Select Investment Option Fund C
	  	$	4,000	  	  	 	4	% 
	 Total Select Investment Options
	  	$	30,000	  	  	 	30	% 
	 Flexible Investment Option Fund A
	  	$	14,000	  	  	 	14	% 
	 Flexible Investment Option Fund B
	  	$	14,000	  	  	 	14	% 
	 Flexible Investment Option Fund C
	  	$	22,000	  	  	 	22	% 
	 Total Flexible Investment Options
	  	$	50,000	  	  	 	50	% 
		  	  
	  
	 	  	  
	  
	 
	 Total Investments
	  	$	100,000	  	  	 	100	% 

 Example 1: Calculation at rider issue for the rebalance allocations: 

The Stable Account portion of the Policy Value is not included in the quarterly Rebalance, therefore the rebalancing allocation percentages are calculated by
multiplying the initial premium allocation percentages for the Select Investment Options and Flexible Investment Options by a ratio. The ratio is calculated by taking 100%, divided by 100% less the Stable Account premium allocation percentage. The
ratio for this example would be 100% / (100% - 20%) = 1.25. 
  

													
	 Investment Option Allocations:
	  	Initial Premium
Allocations	 	  	Initial Premium
Percentages	 	 	Unrounded
Rebalancing
Percentages	 
	 Stable Account
	  	$	20,000	  	  	 	20	% 	 	 	N/A	  
	 Total Select Investment Options
	  	$	30,000	  	  	 	30	% 	 	 	37.5	% 
	 Total Flexible Investment Options
	  	$	50,000	  	  	 	50	% 	 	 	62.5	% 
		  	  
	  
	 	  	  
	  
	 	 	  
	  
	 
	 Total Investments
	  	$	100,000	  	  	 	100	% 	 	 	100.0	% 

 Whole percentages are required for the rebalancing percentages and must sum up to equal 100%. To satisfy this requirement and
ensure the rebalance allocation requirement is met for each of the investment options, the sum of the Select Investment Options rebalancing percentage is rounded to the nearest whole percent (hereafter referred to as Select Rebalance Total) but no
less than the minimum allocation for rebalance. The Select Rebalance Total is deducted from 100% to get the total Flexible Investment Options rebalancing percentage (hereafter referred to as Flexible Rebalance Total). The Select Rebalance Total and
Flexible Rebalance Total percentages are the end result which will be achieved by the quarterly Rebalance. 
 Table 1 

 

									
	 	  	Unrounded
Rebalancing	 	 	Rounded
Rebalancing	 
	 Investment Option Allocations:
	  	Percentages	 	 	Percentages	 
	 Stable Account
	  	 	N/A	  	 	 	N/A	  
	 Total Select Investment Options
	  	 	37.5	% 	 	 	38	% 
	 Total Flexible Investment Options
	  	 	62.5	% 	 	 	62	% 
		  	  
	  
	 	 	  
	  
	 
	 Total Investments
	  	 	100.0	% 	 	 	100	% 

  

					
	NIC16 RGMB510616(IJ)(NY)	  	(A-1)	  	(Income-Joint)

 APPENDIX 
 We
apply the same ratio and rounding to each individual investment option chosen and sum up the total Select and total Flexible Investment Options separately. The totals are compared to Select Rebalance Total and Flexible Rebalance Total to determine
where any adjustments need to be made. In the example below, adjustments will need to be made to the Select Investment Options to bring the total percentage up to 38% and the Flexible Investment Options down to 62%, per the result from Table 1.

 Table 2 
  

													
	 Investment Option Allocations:
	  	Initial Premium
Allocations	 	  	Initial Premium
Percentages	 	 	Rebalancing
Percentages	 
	 Stable Account
	  	$	 20,000	  	  	 	20	% 	 	 	N/A	  
	 Select Investment Option Fund A
	  	$	13,000	  	  	 	13	% 	 	 	16	% 
	 Select Investment Option Fund B
	  	$	13,000	  	  	 	13	% 	 	 	16	% 
	 Select Investment Option Fund C
	  	$	4,000	  	  	 	4	% 	 	 	5	% 
	 Total Select Investment Options
	  	$	30,000	  	  	 	30	% 	 	 	37	% 
	 Flexible Investment Option Fund A
	  	$	14,000	  	  	 	14	% 	 	 	18	% 
	 Flexible Investment Option Fund B
	  	$	14,000	  	  	 	14	% 	 	 	18	% 
	 Flexible Investment Option Fund C
	  	$	22,000	  	  	 	22	% 	 	 	28	% 
	 Total Flexible Investment Options
	  	$	50,000	  	  	 	50	% 	 	 	64	% 
		  	  
	  
	 	  	  
	  
	 	 	  
	  
	 
	 Total Investments
	  	$	100,000	  	  	 	100	% 	 	 	101	% 

 To get the total Select Investment Options rebalancing percent to equal 38%, we must add 1% to one of the funds. Any
adjustments will first be made equally to the fund(s) with the greatest allocation. If there are multiple funds with the greatest allocation and the adjustments cannot be divided equally, we will adjust in alphabetical order the fund(s) with the
greatest allocation. In the example below, we made the adjustment to the Select Investment Option Fund A. 
 To get the total Flexible Investment Options
rebalancing percent to 62%, we must subtract 2% from one or more funds. Since there is only one fund with the greatest allocation, we have made the adjustment to the Flexible Investment Option Fund C. 

Table 3 
  

									
	 Investment Option Allocations:
	  	Pre-Adjusted Rebalancing
Percentages	 	 	Rebalancing
Percentages	 
	 Stable Account
	  	 	N/A	  	 	 	N/A	  
	 Select Investment Option Fund A
	  	 	16	% 	 	 	17	% 
	 Select Investment Option Fund B
	  	 	16	% 	 	 	16	% 
	 Select Investment Option Fund C
	  	 	5	% 	 	 	5	% 
	 Total Select Investment Options
	  	 	37	% 	 	 	38	% 
	 Flexible Investment Option Fund A
	  	 	18	% 	 	 	18	% 
	 Flexible Investment Option Fund B
	  	 	18	% 	 	 	18	% 
	 Flexible Investment Option Fund C
	  	 	28	% 	 	 	26	% 
	 Total Flexible Investment Options
	  	 	64	% 	 	 	62	% 
		  	  
	  
	 	 	  
	  
	 
	 Total Investments
	  	 	101	% 	 	 	100	% 

 Example 2: Calculation for first quarter Rebalance: 

At the end of the first Rider Quarter, assume that the investment options have the following values: 

Table 4 
  

									
	 Investment Option Allocations:
	  	Allocation Amounts
Prior to Rebalance	 	  	Allocation Percentage
of Rebalancing Funds
Prior to Rebalance	 
	 Stable Account
	  	$	20,050	  	  	 	N/A	  
	 Select Investment Option Fund A
	  	$	13,090	  	  	 	17	% 
	 Select Investment Option Fund B
	  	$	11,550	  	  	 	15	% 
	 Select Investment Option Fund C
	  	$	3,850	  	  	 	5	% 
	 Total Select Investment Options
	  	$	28,490	  	  	 	37	% 
	 Flexible Investment Option Fund A
	  	$	13,090	  	  	 	17	% 
	 Flexible Investment Option Fund B
	  	$	14,630	  	  	 	19	% 
	 Flexible Investment Option Fund C
	  	$	20,790	  	  	 	27	% 
	 Total Flexible Investment Options
	  	$	48,510	  	  	 	63	% 
		  	  
	  
	 	  	  
	  
	 
	 Total Investments
	  	$	97,050	  	  	 	100	% 

  

					
	NIC16 RGMB510616(IJ)(NY)	  	(A-2)	  	(Income-Joint)

 APPENDIX 

The result of the Rebalance back to the rebalancing percentages from Table 3 is: 

Table 5 
  

													
	 Investment Option Allocations:
	  	Allocation Amounts
After Rebalancing	 	  	Allocation Percentage
of Rebalancing Funds
After Rebalance	 	 	Allocation Percentage
of Policy Value After
Rebalance	 
	 Stable Account
	  	$	20,050	  	  	 	N/A	  	 	 	21	% 
	 Select Investment Option Fund A
	  	$	13,090	  	  	 	17	% 	 	 	13	% 
	 Select Investment Option Fund B
	  	$	12,320	  	  	 	16	% 	 	 	13	% 
	 Select Investment Option Fund C
	  	$	3,850	  	  	 	5	% 	 	 	4	% 
	 Total Select Investment Options
	  	$	29,260	  	  	 	38	% 	 	 	30	% 
	 Flexible Investment Option Fund A
	  	$	13,860	  	  	 	18	% 	 	 	14	% 
	 Flexible Investment Option Fund B
	  	$	13,860	  	  	 	18	% 	 	 	14	% 
	 Flexible Investment Option Fund C
	  	$	20,020	  	  	 	26	% 	 	 	21	% 
	 Total Flexible Investment Options
	  	$	47,740	  	  	 	62	% 	 	 	49	% 
		  	  
	  
	 	  	  
	  
	 	 	  
	  
	 
	 Total Investments
	  	$	97,050	  	  	 	100	% 	 	 	100	% 

 This rebalancing process will continue on a quarterly basis while this rider is in force. 

Rider Fee Calculation Examples 
 The quarterly fee is
calculated as follows: 
 Multiply (1) by (2) by (3), where: 
  

	1)	is Withdrawal Base 

  

	2)	is rider fee percentage 

  

	3)	is number of days in the Rider Quarter divided by the number of days within the applicable Rider Year 

 The fee
adjustment for additional Premium Payments and Excess Withdrawals is calculated as follows: Multiply (1) by (2) by (3), where: 
  

	1)	is Withdrawal Base change (i.e. Withdrawal Base after the transaction minus the Withdrawal Base before the transaction) 

  

	2)	is rider fee percentage 

  

	3)	is number of days remaining in the Rider Quarter divided by the number of days within the applicable Rider Year 

The following two examples use assumed fees and values. The assumed Rider Year is not a leap year. 

Example 1: Calculation at rider issue for first quarter fee assuming an initial Withdrawal Base of $100,000 and an initial fee percentage of 1.50%.

 = 100,000 * 0.0150 * (91/365) 
 = 1,500 * (91/365) 

= $373.97 
 Example 2: Calculation for first quarter fee
assuming initial Withdrawal Base from Example 1 above, plus adjustment for additional Premium Payment of $10,000 made with 20 days remaining in the first Rider Quarter. The Withdrawal Base change and total transaction amount equal $10,000. 

Fee adjustment as follows: 
 = 10,000 * 0.0150 * (20/365) 

= 150 * (20/365) 
 = $8.22 

  

					
	NIC16 RGMB510616(IJ)(NY)	  	(A-3)	  	(Income-Joint)

 APPENDIX 

Rider Fee Calculation Examples continued 
 Total fee
assessed at end of first Rider Quarter (assuming no further Rider Fee adjustments): 
 = 8.22 + 373.97 

= $382.19 
 The following two examples use assumed fees and
values. The assumed Rider Year is not a leap year. 
 Example 3: Calculation for second quarter fee at beginning of second Rider Quarter, assuming
Withdrawal Base of $110,000 and a fee percentage of 1.50%. 
 = 110,000 * 0.0150 * (91/365) 

= 1,650 * (91/365) 
 = $411.37 

Example 4: Calculation for second quarter fee assuming beginning values as in Example 3 above, plus adjustment for Gross Partial Withdrawal of $10,000
taken with 40 days remaining in the second Rider Quarter. Assumes withdrawal percentage of 5%, Policy Value of $93,500 prior to the transaction and change in Withdrawal Base as follows: 

Rider Withdrawal Amount (RWA) = Withdrawal Base * Withdrawal Percentage = $110,000 * .05 = $5,500 

Excess Withdrawal = Difference between Gross Partial Withdrawal and RWA = $10,000 - $5,500 = $4,500 

Withdrawal Base Adjustment = Max (Excess Withdrawal, Excess Withdrawal * Withdrawal Base prior to withdrawal / Policy Value after RWA has been withdrawn but
before Excess Withdrawal) = Max [$4,500, $4,500 * $110,000 / ($93,500-$5,500)] = Max ($4,500, $5,625) = $5,625 Fee adjustment as follows: 
 = -5,625 *
0.0150 * (40/365) 
 = -84.38 * (40/365) 
 = $-9.25 

Total fee assessed at end of second Rider Quarter (assuming no further Rider Fee adjustments): 

= 411.37 – 9.25 
 = $402.12 

The new Withdrawal Base = $110,000 - $5,625 = $104,375 

  

					
	NIC16 RGMB510616(IJ)(NY)	  	(A-4)	  	(Income-Joint)Exhibit 10.53

 

COMMON STOCK PURCHASE WARRANT

 

XENETIC BIOSCIENCES,
INC.

 

	Warrant Shares:  ___________	Initial Exercise Date: ______, 2016

 

THIS
COMMON STOCK PURCHASE WARRANT (the “Warrant”) certifies that, for value received, __________ or its
assigns (the “Holder”) is entitled, upon the terms and subject to the limitations on exercise and the
conditions hereinafter set forth, at any time on or after __________, 2016 (the “Initial Exercise Date”)
and on or prior to the close of business on the five (5) year anniversary of the Initial Exercise Date (the
“Termination Date”) but not thereafter, to subscribe for and purchase from Xenetic Biosciences, Inc., a
Nevada corporation (the “Company”), up to ______ shares (as subject to adjustment hereunder, the
“Warrant Shares”) of Common Stock. The purchase price of one share of Common Stock under this Warrant
shall be equal to the Exercise Price, as defined in Section 2(b).

 

Section 1.Definitions.The
following terms shall have the meanings indicated in this Section 1:

 

“Affiliate”
means any Person that, directly or indirectly through one or more intermediaries, controls or is controlled by or is under common
control with a Person, as such terms are used in and construed under Rule 405 under the Securities Act.

 

“Board of Directors” means the board
of directors of the Company.

 

“Business
Day” means any day except any Saturday, any Sunday, any day which is a federal legal holiday in the United States or
any day on which banking institutions in the State of New York are authorized or required by law or other governmental action to
close.

 

“Commission” means the United States
Securities and Exchange Commission.

 

“Common
Stock” means the common stock of the Company, par value $0.001 per share, and any other class of securities into which
such securities may hereafter be reclassified or changed.

 

“Common
Stock Equivalents” means any securities of the Company which would entitle the holder thereof to acquire at any time
Common Stock, including, without limitation, any debt, preferred stock, right, option, warrant or other instrument that is at any
time convertible into or exercisable or exchangeable for, or otherwise entitles the holder thereof to receive, Common Stock.

 

“Exchange
Act” means the Securities Exchange Act of 1934, as amended, and the rules and regulations promulgated thereunder.

 

“Person”
means an individual or corporation, partnership, trust, incorporated or unincorporated association, joint venture, limited liability
company, joint stock company, government (or an agency or subdivision thereof) or other entity of any kind.

 

“Registration Statement” means
the Company’s registration statement on Form S-1 (File No. 333-211249).

 

“Securities
Act” means the Securities Act of 1933, as amended, and the rules and regulations promulgated thereunder.

 

    	 	1	 

     

    

 

“Trading Day” means a day on which
the principal Trading Market is open for business.

 

“Trading
Market” means any of the following markets or exchanges on which the Common Stock is listed or quoted for trading on
the date in question: the NYSE MKT, the Nasdaq Capital Market, the Nasdaq Global Market, the Nasdaq Global Select Market or the
New York Stock Exchange (or any successors to any of the foregoing).

 

“Transfer
Agent” means Empire Stock Transfer, the current transfer agent of the Company, with a mailing address of 1859 Whitney
Mesa Drive, Henderson, Nevada 89014, and a telephone number of 702-818-5898, and any successor transfer agent of the Company.

 

Section 2.Exercise.

 

(a) Exercise
of Warrant. Subject to the provisions of Section 2(e) herein, exercise of the purchase rights represented by this Warrant may
be made, in whole or in part, at any time or times on or after the Initial Exercise Date and on or before the Termination Date
by delivery to the Company (or such other office or agency of the Company as it may designate by notice in writing to the registered
Holder at the address of the Holder appearing on the books of the Company) of a duly executed facsimile copy (or e-mail attachment)
of the Notice of Exercise in the form annexed hereto Within the earlier of (i) three (3) Trading Days and (ii) the number of Trading
Days comprising the Standard Settlement Period (as defined in Section 2(d)(i) herein)following the date of exercise as aforesaid,
the Holder shall deliver the aggregate Exercise Price for the shares specified in the applicable Notice of Exercise by wire transfer
or cashier’s check drawn on a United States bank unless the cashless exercise procedure specified in Section 2(c) below is
specified in the applicable Notice of Exercise. No ink-original Notice of Exercise shall be required, nor shall any medallion guarantee
(or other type of guarantee or notarization) of any Notice of Exercise be required. Notwithstanding anything herein to the contrary,
the Holder shall not be required to physically surrender this Warrant to the Company until the Holder has purchased all of the
Warrant Shares available hereunder and the Warrant has been exercised in full, in which case, the Holder shall surrender this Warrant
to the Company for cancellation within three (3) Trading Days of the date the final Notice of Exercise is delivered to the Company.
Partial exercises of this Warrant resulting in purchases of a portion of the total number of Warrant Shares available hereunder
shall have the effect of lowering the outstanding number of Warrant Shares purchasable hereunder in an amount equal to the applicable
number of Warrant Shares purchased. The Holder and the Company shall maintain records showing the number of Warrant Shares purchased
and the date of such purchases. The Company shall deliver any objection to any Notice of Exercise Form within one (1) Business
Day of receipt of such notice. The Holder and any assignee, by acceptance of this Warrant, acknowledge and agree that, by reason
of the provisions of this paragraph, following the purchase of a portion of the Warrant Shares hereunder, the number of Warrant
Shares available for purchase hereunder at any given time may be less than the amount stated on the face hereof.

 

(b)Exercise Price. The exercise price per
share of the Common Stock under this Warrant shall be $            , subject to adjustment hereunder (the “Exercise Price”).

 

    	 	2	 

     

    

 

(c) Cashless
Exercise. If at any time after the Initial Exercise Date, there is no effective registration statement registering, or no current
prospectus available for, the issuance of the Warrant Shares to the Holder, then this Warrant may also be exercised, in whole or
in part, at such time by means of a “cashless exercise” in which the Holder shall be entitled to receive a number of
Warrant Shares equal to the quotient obtained by dividing [(A-B) (X)] by (A), where:

 

(A)
= the last VWAP immediately preceding the time of delivery of the Notice of Exercise giving rise to the applicable “cashless
exercise”, as set forth in the applicable Notice of Exercise (to clarify, the “last VWAP” will be
the last VWAP as calculated over an entire Trading Day such that, in the event that this Warrant is exercised at a time that the
Trading Market is open, the prior Trading Day’s VWAP shall be used in this calculation);(

 

(B) =the Exercise Price of this Warrant, as adjusted
hereunder; and

 

(X)
= the number of Warrant Shares that would be issuable upon exercise of this Warrant in accordance with the terms of this Warrant
if such exercise were by means of a cash exercise rather than a cashless exercise.

 

If Warrant
Shares are issued in such a cashless exercise, the parties acknowledge and agree that in accordance with Section 3(a)(9) of the
Securities Act, the Warrant Shares shall take on the registered characteristics of the Warrants being exercised. The Company agrees
not to take any position contrary to this Section 2(c).

 

“VWAP”
means, for any date, the price determined by the first of the following clauses that applies: (a) if the Common Stock is then listed
or quoted on a Trading Market, the daily volume weighted average price of the Common Stock for such date (or the nearest preceding
date) on the Trading Market on which the Common Stock is then listed or quoted as reported by Bloomberg L.P. (based on a Trading
Day from 9:30 a.m. (New York City time) to 4:02 p.m. (New York City time)), (b) if OTCQB or OTCQX is not a Trading Market, the
volume weighted average price of the Common Stock for such date (or the nearest preceding date) on OTCQB or OTCQX as applicable,
(c) if the Common Stock is not then listed or quoted for trading on OTCQB or OTCQX and if prices for the Common Stock are then
reported in the “Pink Sheets” published by OTC Markets, Inc. (or a similar organization or agency succeeding
to its functions of reporting prices), the most recent bid price per share of the Common Stock so reported, or (d) in all other
cases, the fair market value of a share of Common Stock as determined by an independent appraiser selected in good faith by the
Holders of a majority in interest of the Warrants then outstanding and reasonably acceptable to the Company, the fees and expenses
of which shall be paid by the Company.

 

(d)Mechanics of Exercise.

 

(i) Delivery
of Warrant Shares Upon Exercise. The Company shall cause the Warrant Shares purchased hereunder to be transmitted by the Transfer
Agent to the Holder by crediting the account of the Holder’s or its designee’s balance account with The Depository
Trust Company through its Deposit or Withdrawal at Custodian system (“DWAC”) if the Company is then a participant
in such system and either (A) there is an effective registration statement permitting the issuance of the Warrant Shares to or
resale of the Warrant Shares by the Holder or (B) this Warrant is being exercised via cashless exercise, and otherwise by physical
delivery of a certificate, registered in the Company’s share register in the name of the Holder or its designee, for the
number of Warrant Shares to which the Holder is entitled pursuant to such exercise to the address specified by the Holder in the
Notice of Exercise by the date that is the earlier of (i) one (1) Trading Day and (ii) the number of Trading Days comprising the
Standard Settlement Period after the delivery to the Company of the Notice of Exercise (such date, the “Warrant Share
Delivery Date”). Upon delivery of the Notice of Exercise the Holder shall be deemed for all corporate purposes to have
become the holder of record of the Warrant Shares with respect to which this Warrant has been exercised, irrespective of the date
of delivery of the Warrant Shares; provided that payment of the aggregate Exercise Price (other than in the case of a Cashless
Exercise) is received within the earlier of (i) three Trading Days and (ii) the number of Trading Days comprising the Standard
Settlement Period following delivery of the Notice of Exercise. If the Company fails for any reason to deliver to the Holder the
Warrant Shares subject to a Notice of Exercise by the Warrant Share Delivery Date, the Company shall pay to the Holder, in cash,
as liquidated damages and not as a penalty, for each $1,000 of Warrant Shares subject to such exercise (based on the VWAP of the
Common Stock on the date of the applicable Notice of Exercise), $10 per Trading Day for each Trading Day after such Warrant Share
Delivery Date until such Warrant Shares are delivered or Holder rescinds such exercise. The Company agrees to maintain a transfer
agent that is a participant in the FAST program so long as this Warrant remains outstanding and exercisable. As used herein, “Standard
Settlement Period” means the standard settlement period, expressed in a number of Trading Days, on the Company’s
primary Trading Market with respect to the Common Stock as in effect on the date of delivery of the Notice of Exercise.

 

    	 	3	 

     

    

 

(ii) 
Delivery of New Warrants Upon Exercise. If this Warrant shall have been exercised in part, the Company shall, at the request
of a Holder and upon surrender of this Warrant certificate, at the time of delivery of the Warrant Shares, deliver to the Holder
a new Warrant evidencing the rights of the Holder to purchase the unpurchased Warrant Shares called for by this Warrant, which
new Warrant shall in all other respects be identical with this Warrant.

 

(iii) Rescission
Rights. If the Company fails to cause the Transfer Agent to transmit to the Holder the Warrant Shares pursuant to Section 2(d)(i)
by the Warrant Share Delivery Date, then the Holder will have the right to rescind such exercise.

 

(iv) Compensation
for Buy-In on Failure to Timely Deliver Warrant Shares Upon Exercise. In addition to any other rights available to the Holder,
if the Company fails to cause the Transfer Agent to transmit to the Holder the Warrant Shares in accordance with the provisions
of Section 2(d)(i) above pursuant to an exercise on or before the Warrant Share Delivery Date, and if after such date the Holder
is required by its broker to purchase (in an open market transaction or otherwise) or the Holder’s brokerage firm otherwise
purchases, shares of Common Stock to deliver in satisfaction of a sale by the Holder of the Warrant Shares which the Holder anticipated
receiving upon such exercise (a “Buy-In”), then the Company shall (A) pay in cash to the Holder the amount,
if any, by which (x) the Holder’s total purchase price (including brokerage commissions, if any) for the shares of Common
Stock so purchased exceeds (y) the amount obtained by multiplying (1) the number of Warrant Shares that the Company was required
to deliver to the Holder in connection with the exercise at issue times (2) the price at which the sell order giving rise to such
purchase obligation was executed, and (B) at the option of the Holder, either reinstate the portion of the Warrant and equivalent
number of Warrant Shares for which such exercise was not honored (in which case such exercise shall be deemed rescinded) or deliver
to the Holder the number of shares of Common Stock that would have been issued had the Company timely complied with its exercise
and delivery obligations hereunder. For example, if the Holder purchases Common Stock having a total purchase price of $11,000
to cover a Buy- In with respect to an attempted exercise of shares of Common Stock with an aggregate sale price giving rise to
such purchase obligation of $10,000, under clause (A) of the immediately preceding sentence the Company shall be required to pay
the Holder $1,000. The Holder shall provide the Company written notice indicating the amounts payable to the Holder in respect
of the Buy-In and, upon request of the Company, evidence of the amount of such loss. Nothing herein shall limit a Holder’s
right to pursue any other remedies available to it hereunder, at law or in equity including, without limitation, a decree of specific
performance and/or injunctive relief with respect to the Company’s failure to timely deliver shares of Common Stock upon
exercise of the Warrant as required pursuant to the terms hereof.

 

(v) 
No Fractional Shares or Scrip. No fractional shares or scrip representing fractional shares shall be issued upon the exercise
of this Warrant. As to any fraction of a share which the Holder would otherwise be entitled to purchase upon such exercise, the
Company shall, at its election, either pay a cash adjustment in respect of such final fraction in an amount equal to such fraction
multiplied by the Exercise Price or round up to the next whole share.

 

(vi) Charges,
Taxes and Expenses. Issuance of Warrant Shares shall be made without charge to the Holder for any issue or transfer tax or other
incidental expense in respect of the issuance of Warrant Shares, all of which taxes and expenses shall be paid by the Company,
and such Warrant Shares shall be issued in the name of the Holder or in such name or names as may be directed by the Holder; provided,
however, that in the event that Warrant Shares are to be issued in a name other than the name of the Holder, this Warrant when
surrendered for exercise shall be accompanied by the Assignment Form attached hereto duly executed by the Holder and the Company
may require, as a condition thereto, the payment of a sum sufficient to reimburse it for any transfer tax incidental thereto. The
Company shall pay all Transfer Agent fees required for same-day processing of any Notice of Exercise and all fees to the Depository
Trust Company (or another established clearing corporation performing similar functions) required for same-day electronic delivery
of the Warrant Shares.

 

(vii) Closing
of Books. The Company will not close its stockholder books or records in any manner which prevents the timely exercise of this
Warrant, pursuant to the terms hereof.

 

    	 	4	 

     

    

 

(e) Holder’s
Exercise Limitations. The Company shall not effect any exercise of this Warrant, and a Holder shall not have the right to
exercise any portion of this Warrant, pursuant to Section 2 or otherwise, to the extent that after giving effect to such issuance
after exercise as set forth on the applicable Notice of Exercise, the Holder (together with the Holder’s Affiliates, and
any other Persons acting as a group together with the Holder or any of the Holder’s Affiliates (such Persons, “Attribution
Parties”)), would beneficially own in excess of the Beneficial Ownership Limitation (as defined below). For purposes
of the foregoing sentence, the number of shares of Common Stock beneficially owned by the Holder and its Affiliates and Attribution
Parties shall include the number of shares of Common Stock issuable upon exercise of this Warrant with respect to which such determination
is being made, but shall exclude the number of shares of Common Stock which would be issuable upon (i) exercise of the remaining,
nonexercised portion of this Warrant beneficially owned by the Holder or any of its Affiliates or Attribution Parties and (ii)
exercise or conversion of the unexercised or nonconverted portion of any other securities of the Company (including, without limitation,
any other Common Stock Equivalents) subject to a limitation on conversion or exercise analogous to the limitation contained herein
beneficially owned by the Holder or any of its Affiliates or Attribution Parties. Except as set forth in the preceding sentence,
for purposes of this Section 2(e), beneficial ownership shall be calculated in accordance with Section 13(d) of the Exchange Act
and the rules and regulations promulgated thereunder, it being acknowledged by the Holder that the Company is not representing
to the Holder that such calculation is in compliance with Section 13(d) of the Exchange Act and the Holder is solely responsible
for any schedules required to be filed in accordance therewith. To the extent that the limitation contained in this Section 2(e)
applies, the determination of whether this Warrant is exercisable (in relation to other securities owned by the Holder together
with any Affiliates and Attribution Parties) and of which portion of this Warrant is exercisable shall be in the sole discretion
of the Holder, and the submission of a Notice of Exercise shall be deemed to be the Holder’s determination of whether this
Warrant is exercisable (in relation to other securities owned by the Holder together with any Affiliates and Attribution Parties)
and of which portion of this Warrant is exercisable, in each case subject to the Beneficial Ownership Limitation, and the Company
shall have no obligation to verify or confirm the accuracy of such determination. In addition, a determination as to any group
status as contemplated above shall be determined in accordance with Section 13(d) of the Exchange Act and the rules and regulations
promulgated thereunder. For purposes of this Section 2(e), in determining the number of outstanding shares of Common Stock, a
Holder may rely on the number of outstanding shares of Common Stock as reflected in (A) the Company’s most recent periodic
or annual report filed with the Commission, as the case may be, (B) a more recent public announcement by the Company or (C) a
more recent written notice by the Company or the Transfer Agent setting forth the number of shares of Common Stock outstanding.
Upon the written or oral request of a Holder, the Company shall within two Trading Days confirm orally and in writing to the Holder
the number of shares of Common Stock then outstanding. In any case, the number of outstanding shares of Common Stock shall be
determined after giving effect to the conversion or exercise of securities of the Company, including this Warrant, by the Holder
or its Affiliates or Attribution Parties since the date as of which such number of outstanding shares of Common Stock was reported.
The “Beneficial Ownership Limitation” shall be 4.99% of the number of shares of the Common Stock outstanding
immediately after giving effect to the issuance of shares of Common Stock issuable upon exercise of this Warrant. The Holder,
upon notice to the Company, may increase or decrease the Beneficial Ownership Limitation provisions of this Section 2(e),
provided that the Beneficial Ownership Limitation in no event exceeds 9.99% of the number of shares of the Common Stock outstanding
immediately after giving effect to the issuance of shares of Common Stock upon exercise of this Warrant held by the Holder and
the provisions of this Section 2(e) shall continue to apply. Any increase in the Beneficial Ownership Limitation will not be effective
until the 61st day after such notice is delivered to the Company. The provisions of this paragraph shall be construed and implemented
in a manner otherwise than in strict conformity with the terms of this Section 2(e) to correct this paragraph (or any portion
hereof) which may be defective or inconsistent with the intended Beneficial Ownership Limitation herein contained or to make changes
or supplements necessary or desirable to properly give effect to such limitation. The limitations contained in this paragraph
shall apply to a successor holder of this Warrant.

 

    	 	5	 

     

    

 

Section
3. Certain Adjustments.

 

(a) Stock
Dividends and Splits. If the Company, at any time while this Warrant is outstanding: (i) pays a stock dividend or otherwise
makes a distribution or distributions on shares of its Common Stock or any other equity or equity equivalent securities payable
in shares of Common Stock (which, for avoidance of doubt, shall not include any shares of Common Stock issued by the Company upon
exercise of this Warrant), (ii) subdivides outstanding shares of Common Stock into a larger number of shares, (iii) combines (including
by way of reverse stock split) outstanding shares of Common Stock into a smaller number of shares or (iv) issues by reclassification
of shares of the Common Stock any shares of capital stock of the Company, then in each case the Exercise Price shall be multiplied
by a fraction of which the numerator shall be the number of shares of Common Stock (excluding treasury shares, if any) outstanding
immediately before such event and of which the denominator shall be the number of shares of Common Stock outstanding immediately
after such event, and the number of shares issuable upon exercise of this Warrant shall be proportionately adjusted such that the
aggregate Exercise Price of this Warrant shall remain unchanged. Any adjustment made pursuant to this Section 3(a) shall become
effective immediately after the record date for the determination of stockholders entitled to receive such dividend or distribution
and shall become effective immediately after the effective date in the case of a subdivision, combination or re-classification.

 

(b)During such time as this
Warrant is outstanding, if the Company shall declare or make any dividend or other distribution of its assets (or rights to acquire
its assets) to holders of shares of Common Stock, by way of return of capital or otherwise (including, without limitation, any
distribution of cash, stock or other securities, property or options by way of a dividend, spin off, reclassification, corporate
rearrangement, scheme of arrangement or other similar transaction) (a “Distribution”), at any time after the
issuance of this Warrant, then, in each such case, the Holder shall be entitled to participate in such Distribution to the same
extent that the Holder would have participated therein if the Holder had held the number of shares of Common Stock acquirable upon
complete exercise of this Warrant (without regard to any limitations on exercise hereof, including without limitation, the Beneficial
Ownership Limitation) immediately before the date of which a record is taken for such Distribution, or, if no such record is taken,
the date as of which the record holders of shares of Common Stock are to be determined for the participation in such Distribution
(provided, however, to the extent that the Holder's right to participate in any such Distribution would result in
the Holder exceeding the Beneficial Ownership Limitation, then the Holder shall not be entitled to participate in such Distribution
to such extent (or in the beneficial ownership of any shares of Common Stock as a result of such Distribution to such extent) and
the portion of such Distribution shall be held in abeyance for the benefit of the Holder until such time, if ever, as its right
thereto would not result in the Holder exceeding the Beneficial Ownership Limitation). To the extent that this Warrant has not
been partially or completely exercised at the time of such Distribution, such portion of the Distribution shall be held in abeyance
for the benefit of the Holder until the Holder has exercised this Warrant.

 

(c)Subsequent Rights Offerings. In addition
to any adjustments pursuant to Section 3(a) above, if at any time the Company grants, issues or sells any Common Stock Equivalents
or rights to purchase stock, warrants, securities or other property pro rata to the record holders of any class of shares of Common
Stock (the “Purchase Rights”), then the Holder will be entitled to acquire, upon the terms applicable to such
Purchase Rights, the aggregate Purchase Rights which the Holder could have acquired if the Holder had held the number of shares
of Common Stock acquirable upon complete exercise of this Warrant (without regard to any limitations on exercise hereof, including
without limitation, the Beneficial Ownership Limitation) immediately before the date on which a record is taken for the grant,
issuance or sale of such Purchase Rights, or, if no such record is taken, the date as of which the record holders of shares of
Common Stock are to be determined for the grant, issue or sale of such Purchase Rights (provided, however, to the extent that
the Holder’s right to participate in any such Purchase Right would result in the Holder exceeding the Beneficial Ownership
Limitation, then the Holder shall not be entitled to participate in such Purchase Right to such extent (or beneficial ownership
of such shares of Common Stock as a result of such Purchase Right to such extent) and such Purchase Right to such extent shall
be held in abeyance for the Holder until such time, if ever, as its right thereto would not result in the Holder exceeding the
Beneficial Ownership Limitation).

 

    	 	6	 

     

    

 

(d)
Fundamental Transaction. If, at any time while this Warrant is outstanding, (i) the Company, directly or indirectly, in
one or more related transactions effects any merger or consolidation of the Company with or into another Person, (ii) the Company,
directly or indirectly, effects any sale, lease, license, assignment, transfer, conveyance or other disposition of all or substantially
all of its assets in one or a series of related transactions, (iii) any, direct or indirect, purchase offer, tender offer or exchange
offer (whether by the Company or another Person) is completed pursuant to which holders of Common Stock are permitted to sell,
tender or exchange their shares for other securities, cash or property and has been accepted by the holders of 50% or more of
the outstanding Common Stock, (iv) the Company, directly or indirectly, in one or more related transactions effects any reclassification,
reorganization or recapitalization of the Common Stock or any compulsory share exchange pursuant to which the Common Stock is
effectively converted into or exchanged for other securities, cash or property, or (v) the Company, directly or indirectly, in
one or more related transactions consummates a stock or share purchase agreement or other business combination (including, without
limitation, a reorganization, recapitalization, spin-off or scheme of arrangement) with another Person or group of Persons whereby
such other Person or group acquires more than 50% of the outstanding shares of Common Stock (not including any shares of Common
Stock held by the other Person or other Persons making or party to, or associated or affiliated with the other Persons making
or party to, such stock or share purchase agreement or other business combination) (each a “Fundamental Transaction”),
then, upon any subsequent exercise of this Warrant, the Holder shall have the right to receive, for each Warrant Share that would
have been issuable upon such exercise immediately prior to the occurrence of such Fundamental Transaction, at the option of the
Holder (without regard to any limitation in Section 2(e) on the exercise of this Warrant), the number of shares of Common Stock
of the successor or acquiring corporation or of the Company, if it is the surviving corporation, and any additional consideration
(the “Alternate Consideration”) receivable as a result of such Fundamental Transaction by a holder of the number
of shares of Common Stock for which this Warrant is exercisable immediately prior to such Fundamental Transaction (without regard
to any limitation in Section 2(e) on the exercise of this Warrant). For purposes of any such exercise, the determination of the
Exercise Price shall be appropriately adjusted to apply to such Alternate Consideration based on the amount of Alternate Consideration
issuable in respect of one share of Common Stock in such Fundamental Transaction, and the Company shall apportion the Exercise
Price among the Alternate Consideration in a reasonable manner reflecting the relative value of any different components of the
Alternate Consideration. If holders of Common Stock are given any choice as to the securities, cash or property to be received
in a Fundamental Transaction, then the Holder shall be given the same choice as to the Alternate Consideration it receives upon
any exercise of this Warrant following such Fundamental Transaction. Notwithstanding anything to the contrary, in the event of
a Fundamental Transaction that is (1) an all cash transaction, (2) a “Rule 13e-3 transaction” as defined in
Rule 13e-3 under the Exchange Act, or (3) a Fundamental Transaction only if such Fundamental Transaction is within the Company’s
control, the Company or any Successor Entity (as defined below) shall, at the Holder’s option, exercisable at any time concurrently
with, or within 30 days after, the consummation of the Fundamental Transaction, purchase this Warrant from the Holder by paying
to the Holder an amount of cash equal to the Black Scholes Value of the remaining unexercised portion of this Warrant on the date
of the consummation of such Fundamental Transaction; provided, however, if the Fundamental Transaction is not within the Company’s
control for purposes of GAAP (with reference to EITF 00-19), including not approved by the Company’s Board of Directors,
Holder shall have not have the option to require the Company to purchase its Warrant. “Black Scholes Value”
means the value of this Warrant based on the Black and Scholes Option Pricing Model obtained from the “OV”
function on Bloomberg, L.P. (“Bloomberg”) determined as of the day of consummation of the applicable Fundamental
Transaction for pricing purposes and reflecting (A) a risk-free interest rate corresponding to the U.S. Treasury rate for a period
equal to the time between the date of the public announcement of the applicable Fundamental Transaction and the Termination Date,
(B) an expected volatility equal to the greater of 100% and the 100 day volatility obtained from the HVT function on Bloomberg
as of the Trading Day immediately following the public announcement of the applicable Fundamental Transaction, (C) the underlying
price per share used in such calculation shall be the sum of the price per share being offered in cash, if any, plus the value
of any non-cash consideration, if any, being offered in such Fundamental Transaction and (D) a remaining option time equal to
the time between the date of the public announcement of the applicable Fundamental Transaction and the Termination Date. The payment
of the Black Scholes Value will be made by wire transfer of immediately available funds within five Business Days of the Holder’s
election (or, if later, on the effective date of the Fundamental Transaction).The Company shall cause any successor entity in
a Fundamental Transaction in which the Company is not the survivor (the “Successor Entity”) to assume in writing
all of the obligations of the Company under this Warrant and the other Transaction Documents in accordance with the provisions
of this Section 3(d) pursuant to written agreements prior to such Fundamental Transaction and shall, at the option of the Holder,
deliver to the Holder in exchange for this Warrant a security of the Successor Entity evidenced by a written instrument substantially
similar in form and substance to this Warrant which is exercisable for a corresponding number of shares of capital stock of such
Successor Entity (or its parent entity) equivalent to the shares of Common Stock acquirable and receivable upon exercise of this
Warrant (without regard to any limitations on the exercise of this Warrant) prior to such Fundamental Transaction, and with an
exercise price which applies the exercise price hereunder to such shares of capital stock (but taking into account the relative
value of the shares of Common Stock pursuant to such Fundamental Transaction and the value of such shares of capital stock, such
number of shares of capital stock and such exercise price being for the purpose of protecting the economic value of this Warrant
immediately prior to the consummation of such Fundamental Transaction), and which is reasonably satisfactory in form and substance
to the Holder. Upon the occurrence of any such Fundamental Transaction, the Successor Entity shall succeed to, and be substituted
for (so that from and after the date of such Fundamental Transaction, the provisions of this Warrant and the other Transaction
Documents referring to the “Company” shall refer instead to the Successor Entity), and may exercise every right
and power of the Company and shall assume all of the obligations of the Company under this Warrant and the other Transaction Documents
with the same effect as if such Successor Entity had been named as the Company herein. For the avoidance of doubt, if, at any
time while this Warrant is outstanding, a Fundamental Transaction occurs, pursuant to the terms of this Section 5(e), the Holder
shall not be entitled to receive more than one of (i) the consideration receivable as a result of such Fundamental Transaction
by a holder of the number of shares of Common Stock for which this Warrant is exercisable immediately prior to such Fundamental
Transaction, (ii) an amount of cash equal to the Black Scholes Value of the remaining unconverted portion of this Warrant on the
date of the consummation of such Fundamental Transaction, or (iii) the assumption by the Successor Entity of all of the obligations
of the Company under this Warrant and the other Transaction Documents and the option to receive a security of the Successor Entity
evidenced by a written instrument substantially similar in form and substance to this Warrant.

    	 	7	 

     

    

 

(e) Calculations.
All calculations under this Section 3 shall be made to the nearest cent or the nearest 1/100th of a share, as the case may
be. For purposes of this Section 3, the number of shares of Common Stock deemed to be issued and outstanding as of a given date
shall be the sum of the number of shares of Common Stock (excluding treasury shares, if any) issued and outstanding.

 

(f)Notice to Holder.

 

(i) Adjustment
to Exercise Price. Whenever the Exercise Price is adjusted pursuant to any provision of this Section 3, the Company shall
promptly deliver to the Holder by facsimile or e-mail a notice setting forth the Exercise Price after such adjustment and any resulting
adjustment to the number of Warrant Shares and setting forth a brief statement of the facts requiring such adjustment.

 

(ii) Notice
to Allow Exercise by Holder. If (A) the Company shall declare a dividend (or any other distribution in whatever form) on the Common
Stock, (B) the Company shall declare a special nonrecurring cash dividend on or a redemption of the Common Stock, (C) the Company
shall authorize the granting to all holders of the Common Stock rights or warrants to subscribe for or purchase any shares of capital
stock of any class or of any rights, (D) the approval of any stockholders of the Company shall be required in connection with any
reclassification of the Common Stock, any consolidation or merger to which the Company is a party, any sale or transfer of all
or substantially all of the assets of the Company, or any compulsory share exchange whereby the Common Stock is converted into
other securities, cash or property, or (E) the Company shall authorize the voluntary or involuntary dissolution, liquidation or
winding up of the affairs of the Company, then, in each case, the Company shall cause to be delivered by facsimile or e-mail to
the Holder at its last facsimile number or email address as it shall appear upon the Warrant Register of the Company, at least
20 calendar days prior to the applicable record or effective date hereinafter specified, a notice stating (x) the date on which
a record is to be taken for the purpose of such dividend, distribution, redemption, rights or warrants, or if a record is not to
be taken, the date as of which the holders of the Common Stock of record to be entitled to such dividend, distributions, redemption,
rights or warrants are to be determined or (y) the date on which such reclassification, consolidation, merger, sale, transfer or
share exchange is expected to become effective or close, and the date as of which it is expected that holders of the Common Stock
of record shall be entitled to exchange their shares of the Common Stock for securities, cash or other property deliverable upon
such reclassification, consolidation, merger, sale, transfer or share exchange; provided that the failure to deliver such notice
or any defect therein or in the delivery thereof shall not affect the validity of the corporate action required to be specified
in such notice. To the extent that any notice provided in this Warrant constitutes, or contains, material, non-public information
regarding the Company or any of the Subsidiaries, the Company shall simultaneously file such notice with the Commission pursuant
to a Current Report on Form 8-K. The Holder shall remain entitled to exercise this Warrant during the period commencing on the
date of such notice to the effective date of the event triggering such notice except as may otherwise be expressly set forth herein.

 

    	 	8	 

     

    

 

Section 4.Transfer
of Warrant.

 

(a)Transferability.
This Warrant and all rights hereunder are transferable, in whole or in part, upon surrender of this Warrant at the principal office
of the Company or its designated agent, together with a written assignment of this Warrant substantially in the form attached
hereto duly executed by the Holder or its agent or attorney and funds sufficient to pay any transfer taxes payable upon the making
of such transfer. Upon such surrender and, if required, such payment, the Company shall execute and deliver a new Warrant or Warrants
in the name of the assignee or assignees, as applicable, and in the denomination or denominations specified in such instrument
of assignment, and shall issue to the assignor a new Warrant evidencing the portion of this Warrant not so assigned, and this
Warrant shall promptly be cancelled. Notwithstanding anything herein to the contrary, the Holder shall not be required to physically
surrender this Warrant to the Company unless the Holder has assigned this Warrant in full, in which case, the Holder shall surrender
this Warrant to the Company within three (3) Trading Days of the date the Holder delivers an assignment form to the Company assigning
this Warrant full. The Warrant, if properly assigned in accordance herewith, may be exercised by a new holder for the purchase
of Warrant Shares without having a new Warrant issued.

 

(b) New
Warrants. This Warrant may be divided or combined with other Warrants upon presentation hereof at the aforesaid office of the
Company, together with a written notice specifying the names and denominations in which new Warrants are to be issued, signed by
the Holder or its agent or attorney. Subject to compliance with Section 4(a), as to any transfer which may be involved in such
division or combination, the Company shall execute and deliver a new Warrant or Warrants in exchange for the Warrant or Warrants
to be divided or combined in accordance with such notice. All Warrants issued on transfers or exchanges shall be dated the original
Initial Exercise Date and shall be identical with this Warrant except as to the number of Warrant Shares issuable pursuant thereto.

 

(c) Warrant
Register. The Company shall register this Warrant, upon records to be maintained by the Company for that purpose (the “Warrant
Register”), in the name of the record Holder hereof from time to time. The Company may deem and treat the registered
Holder of this Warrant as the absolute owner hereof for the purpose of any exercise hereof or any distribution to the Holder, and
for all other purposes, absent actual notice to the contrary.

 

Section
5. Miscellaneous.

 

(a) No
Rights as Stockholder Until Exercise. This Warrant does not entitle the Holder to any voting rights, dividends or other rights
as a stockholder of the Company prior to the exercise hereof as set forth in Section 2(d)(i), except as expressly set forth in
Section 3.

 

(b) Loss,
Theft, Destruction or Mutilation of Warrant. The Company covenants that upon receipt by the Company of evidence reasonably
satisfactory to it of the loss, theft, destruction or mutilation of this Warrant or any stock certificate relating to the Warrant
Shares, and in case of loss, theft or destruction, of indemnity or security reasonably satisfactory to it (which, in the case of
the Warrant, shall not include the posting of any bond), and upon surrender and cancellation of such Warrant or stock certificate,
if mutilated, the Company will make and deliver a new Warrant or stock certificate of like tenor and dated as of such cancellation,
in lieu of such Warrant or stock certificate.

 

(c) Saturdays,
Sundays, Holidays, etc. If the last or appointed day for the taking of any action or the expiration of any right required or
granted herein shall not be a Business Day, then, such action may be taken or such right may be exercised on the next succeeding
Business Day.

 

    	 	9	 

     

    

 

(d)Authorized Shares.

 

The Company
covenants that, during the period the Warrant is outstanding, it will reserve from its authorized and unissued Common Stock a sufficient
number of shares to provide for the issuance of the Warrant Shares upon the exercise of any purchase rights under this Warrant.
The Company further covenants that its issuance of this Warrant shall constitute full authority to its officers who are charged
with the duty of issuing the necessary Warrant Shares upon the exercise of the purchase rights under this Warrant. The Company
will take all such reasonable action as may be necessary to assure that such Warrant Shares may be issued as provided herein without
violation of any applicable law or regulation, or of any requirements of the Trading Market upon which the Common Stock may be
listed. The Company covenants that all Warrant Shares which may be issued upon the exercise of the purchase rights represented
by this Warrant will, upon exercise of the purchase rights represented by this Warrant and payment for such Warrant Shares in accordance
herewith, be duly authorized, validly issued, fully paid and nonassessable and free from all taxes, liens and charges created by
the Company in respect of the issue thereof (other than taxes in respect of any transfer occurring contemporaneously with such
issue).

 

Except
and to the extent as waived or consented to by the Holder, the Company shall not by any action, including, without limitation,
amending its certificate of incorporation or through any reorganization, transfer of assets, consolidation, merger, dissolution,
issue or sale of securities or any other voluntary action, avoid or seek to avoid the observance or performance of any of the terms
of this Warrant, but will at all times in good faith assist in the carrying out of all such terms and in the taking of all such
actions as may be necessary or appropriate to protect the rights of Holder as set forth in this Warrant against impairment. Without
limiting the generality of the foregoing, the Company will (i) not increase the par value of any Warrant Shares above the amount
payable therefor upon such exercise immediately prior to such increase in par value, (ii) take all such action as may be necessary
or appropriate in order that the Company may validly and legally issue fully paid and nonassessable Warrant Shares upon the exercise
of this Warrant and (iii) use commercially reasonable efforts to obtain all such authorizations, exemptions or consents from any
public regulatory body having jurisdiction thereof, as may be, necessary to enable the Company to perform its obligations under
this Warrant.

 

Before taking
any action which would result in an adjustment in the number of Warrant Shares for which this Warrant is exercisable or in the
Exercise Price, the Company shall obtain all such authorizations or exemptions thereof, or consents thereto, as may be necessary
from any public regulatory body or bodies having jurisdiction thereof.

 

(e) Governing
Law. All questions concerning the construction, validity, enforcement and interpretation of this Warrant shall be governed
by and construed and enforced in accordance with the internal laws of the State of New York, without regard to the principles
of conflict of laws thereof. Each party agrees that all legal proceedings concerning the interpretation, enforcement and defense
of this Warrant shall be commenced in the state and federal courts sitting in the City of New York, Borough of Manhattan (the
“New York Courts”). Each party hereto hereby irrevocably submits to the exclusive jurisdiction of the New York
Courts for the adjudication of any dispute hereunder or in connection herewith or with any transaction contemplated hereby or
discussed herein (including with respect to the enforcement of any of the Transaction Documents), and hereby irrevocably waives,
and agrees not to assert in any suit, action or proceeding, any claim that it is not personally subject to the jurisdiction of
such New York Courts, or such New York Courts are improper or inconvenient venue for such proceeding. Each party hereto hereby
irrevocably waives, to the fullest extent permitted by applicable law, any and all right to trial by jury in any legal proceeding
arising out of or relating to this Warrant. If any party shall commence an action or proceeding to enforce any provisions of this
Warrant, then the prevailing party in such action or proceeding shall be reimbursed by the other party for its attorneys’
fees and other costs and expenses incurred in the investigation, preparation and prosecution of such action or proceeding.

 

    	 	10	 

     

    

 

(f) Restrictions.
The Holder acknowledges that the Warrant Shares acquired upon the exercise of this Warrant, if not registered and the Holder does
not utilize cashless exercise, will have restrictions upon resale imposed by state and federal securities laws.

 

(g) Nonwaiver
and Expenses. No course of dealing or any delay or failure to exercise any right hereunder on the part of Holder shall operate
as a waiver of such right or otherwise prejudice the Holder’s rights, powers or remedies. If the Company willfully and knowingly
fails to comply with any provision of this Warrant, which results in any material damages to the Holder, the Company shall pay
to the Holder such amounts as shall be sufficient to cover any costs and expenses including, but not limited to, reasonable attorneys’
fees, including those of appellate proceedings, incurred by the Holder in collecting any amounts due pursuant hereto or in otherwise
enforcing any of its rights, powers or remedies hereunder.

 

(h) Notices.
Any and all notices or other communications or deliveries to be provided by the Holders hereunder including, without
limitation, any Notice of Exercise, shall be in writing and delivered personally, by facsimile, or sent by a nationally
recognized overnight courier service, addressed to the Company, at 99 Hayden Avenue, Suite 230, Lexington, MA 02421,
Attention: Chief Executive Officer, facsimile number: 781-538-4327, email address: s.maguire@xeneticbio.com,
or such other facsimile number, email address or address as the Company may specify for such purposes by notice to the
Holders. Any and all notices or other communications or deliveries to be provided by the Company hereunder shall be in
writing and delivered personally, by facsimile, or sent by a nationally recognized overnight courier service addressed to
each Holder at the facsimile number or address of such Holder appearing on the books of the Company, or if no such facsimile
number or address appears on the books of the Company. Any notice or other communication or deliveries hereunder shall be
deemed given and effective on the earliest of (i) the date of transmission, if such notice or communication is delivered via
facsimile at the facsimile number set forth in this Section prior to 5:30 p.m. (New York City time) on any date, (ii) the
next Trading Day after the date of transmission, if such notice or communication is delivered via facsimile at the facsimile
number set forth in this Section on a day that is not a Trading Day or later than 5:30 p.m. (New York City time) on any
Trading Day, (iii) the second Trading Day following the date of mailing, if sent by U.S. nationally recognized overnight
courier service, or (iv) upon actual receipt by the party to whom such notice is required to be given.

 

(i) Limitation
of Liability. No provision hereof, in the absence of any affirmative action by the Holder to exercise this Warrant to purchase
Warrant Shares, and no enumeration herein of the rights or privileges of the Holder, shall give rise to any liability of the Holder
for the purchase price of any Common Stock or as a stockholder of the Company, whether such liability is asserted by the Company
or by creditors of the Company.

 

(j) Remedies.
The Holder, in addition to being entitled to exercise all rights granted by law, including recovery of damages, will be
entitled to specific performance of its rights under this Warrant. The Company agrees that monetary damages would not be
adequate compensation for any loss incurred by reason of a breach by it of the provisions of this Warrant and hereby
agrees to waive and not to assert the defense in any action for specific performance that a remedy at law would be
adequate.

 

    	 	11	 

     

    

 

(k) Successors
and Assigns. Subject to applicable securities laws, this Warrant and the rights and obligations evidenced hereby shall inure
to the benefit of and be binding upon the successors and permitted assigns of the Company and the successors and permitted assigns
of Holder. The provisions of this Warrant are intended to be for the benefit of any Holder from time to time of this Warrant and
shall be enforceable by the Holder or holder of Warrant Shares.

 

(l) Amendment.
This Warrant may be modified or amended or the provisions hereof waived with the written consent of the Company and the Holder.

 

(m) Severability.
Wherever possible, each provision of this Warrant shall be interpreted in such manner as to be effective and valid under applicable
law, but if any provision of this Warrant shall be prohibited by or invalid under applicable law, such provision shall be ineffective
to the extent of such prohibition or invalidity, without invalidating the remainder of such provisions or the remaining provisions
of this Warrant.

 

(n) Headings.
The headings used in this Warrant are for the convenience of reference only and shall not, for any purpose, be deemed a part of
this Warrant.

 

********************

(Signature Page Follows)

 

 

 

 

 

    	 	12	 

     

    

 

IN WITNESS WHEREOF, the Company
has caused this Warrant to be executed by its officer thereunto duly authorized as of the date first above indicated.

 

 

	 	 XENETIC BIOSCIENCES, INC.

 

 

 

By: _____________________

Name:

Title:

 

 

 

 

 

 

 

 

    	 	13	 

     

    

 

NOTICE OF EXERCISE

 

TO: XENETIC BIOSCIENCES, INC.

 

(1)The undersigned hereby elects to purchase Warrant
Shares of the Company pursuant to the terms of the attached Warrant (only if exercised in full), and tenders herewith payment
of the exercise price in full, together with all applicable transfer taxes, if any.

 

(2)Payment
shall take the form of (check applicable box):

 

☐ in lawful money of the United States; or

 

☐
if permitted the cancellation of such number of Warrant Shares as is necessary, in accordance with the formula set forth in
subsection 2(c), to exercise this Warrant with respect to the maximum number of Warrant Shares purchasable pursuant to the
cashless exercise procedure set forth in subsection 2(c).

 

(3)Please issue said Warrant
Shares in the name of the undersigned or in such other name as is specified below:

 

____________________________

 

The
Warrant Shares shall be delivered to the following DWAC Account Number:

 

____________________________

 

____________________________

 

____________________________

 

[SIGNATURE OF HOLDER]

 

	Name of Investing Entity:	 	 
	 	 	 
	Signature of Authorized Signatory of Investing Entity:	 
	 	 
	Name of Authorized Signatory:	 	 
	 	 	 
	Title of Authorized Signatory:	 	 
	 	 	 
	Date: 	 	 	 

 

 

 

    	 	14	 

     

    

 

EXHIBIT B

 

ASSIGNMENT FORM

 

(To assign the foregoing Warrant, execute this
form and supply required information. Do not use this form to purchase shares.)

 

FOR VALUE RECEIVED, the foregoing Warrant and all rights
evidenced thereby are hereby assigned to

 

	Name:	 	 
	 	 	(Please Print)
	 	 	 
	Address:	 	 
	 	 	 
	 	 	(Please Print)
	 	 	 
	Phone
Number:	 	 
	 	 	 
	 	 	 
	 	 	 
	 	 	 
	Email
Address:	 	 
	 	 	 
	Dated: ______________, ______	 
	 	 	 
	Holder’s Signature: 	 	 
	 	 	 
	Holder’s Address:	 	 

 

 

 

 

 

 

 

 

 

    	 	15

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