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

INDIVIDUAL RETIREMENT ANNUITY ENDORSEMENT

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

	1.	 	The Owner, Annuitant and Payee shall be the same individual. The Owner, Annuitant and Payee
cannot be changed, except as otherwise permitted under the Code and applicable regulations.
All distributions made while the Owner is alive must be made to the Owner.
	 
	2.	 	The interest of the Owner under this Contract shall be nonforfeitable except as provided by
law.
	 
	3.	 	This Contract may not be sold, assigned, discounted, pledged as collateral for a loan or as
security for the performance of any obligation or for any other purpose, or otherwise
transferred (other than a transfer incident to a divorce or separation instrument in
accordance with Section 408(d)(6) of the Code) to any person other than to the Company.
	 
	4.	 	This Contract is established for the exclusive benefit of the Owner and his or her
Beneficiary(ies). If this is an inherited IRA within the meaning of Code § 408(d)(3)(C)
maintained for the benefit of a designated beneficiary of a deceased Owner, references in this
Endorsement to the “Owner” are to the deceased Owner.
	 
	5.	 	Purchase Payment(s) are flexible. You may change the amounts, frequency and/or timing of
Purchase Payments.
	 
	6.	 	(a) Except in the case of a rollover contribution (as permitted by Code§§ 402(c), 402(e)(6),
403(a)(4), 403(b)(8), 403(b)(10), 408(d)(3) and 457(e)(16)) or a contribution made in
accordance with the terms of a Simplified Employee Pension (SEP) as described in § 408(k), no
contributions will be accepted unless they are in cash, and the total of such contributions
shall not exceed $5,000 for any taxable year beginning in 2008 and years thereafter.

After 2008, the limit will be adjusted by the Secretary of the Treasury for cost-of-living
increases under Code § 219(b)(5)(D). Such adjustments will be in multiples of $500.

(b) In the case of an individual who is age 50 or older, the annual cash contribution limit
is increased by$1,000 for any taxable year beginning in 2006 and years thereafter.

(c) In addition to the amounts described in paragraphs (a) and (b) above, an individual may
make additional contributions specifically authorized by statute – such as repayments of
qualified reservist distributions, repayments of certain plan distributions made on account
of a federally declared disaster and certain amounts received in connection with the Exxon
Valdez litigation.

(d) In addition to the amounts described in paragraphs (a) and (c) above, an individual who
was a participant in a § 401(k) plan of a certain employer in bankruptcy described in Code §
219(b) (5)(C) may contribute up to $3,000 for taxable years beginning after 2006 and before
2010 only.

	 	 	 	 	 

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An individual who makes contributions under this paragraph (d) may not also make
contributions under paragraph (b).

(e) No contributions will be accepted under a SIMPLE IRA plan established by any employer
pursuant to § 408(p). Also, no transfer or rollover of funds attributable to contributions
made by a particular employer under its SIMPLE IRA plan will be accepted from a SIMPLE IRA,
that is, an IRA used in conjunction with a SIMPLE IRA plan, prior to the expiration of the
2-year period beginning on the date the Owner first participated in that employer’s SIMPLE
IRA plan.

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

	7.	 	Any refund of premiums (other than those attributable to excess contributions) will be
applied, before the close of the calendar year following the year of the refund, toward the
payment of future premiums or the purchase of additional benefits.
	 
	8.	 	(a) Notwithstanding any provision of this IRA to the contrary, the distribution of the
Owner’s interest in the IRA shall be made in accordance with the requirements of Code
§ 408(b)(3) and the regulations thereunder, the provisions of which are herein incorporated by
reference. If distributions are not made in the form of an annuity on an irrevocable basis
(except for acceleration), then distribution of the interest in the IRA (as determined under
section 9 (c)) must satisfy the requirements of Code § 408(a)(6) and the regulations
thereunder, rather than paragraphs (b), (c) and (d) below and section 9.

(b) The entire interest of the Owner for whose benefit the Contract is maintained will
commence to be distributed no later than the first day of April following the calendar year
in which such Owner attains age 701/2 (the “required beginning date”) over: (a) the life of
such individual or the lives of such individual and his or her designated beneficiary or (b)
a period certain not extending beyond the life expectancy of such individual or the joint
and last survivor expectancy of such individual and his or her designated beneficiary.
Payments must be made in periodic payments at intervals of no longer than 1 year and must be
either nonincreasing or they may increase only as provided in Q&As-1 and -4 of
§ 1.401(a)(9)-6 of the Income Tax Regulations. In addition, any distribution must satisfy
the incidental benefit requirements specified in Q&A-2 of § 1.401(a)(9)-6. If this is an
inherited IRA within the meaning of § 408(d)(3)(C), this paragraph and paragraphs (c) and
(d) below do not apply.

(c) The distribution periods described in paragraph (b) above cannot exceed the periods
specified in § 1.401(a)(9)-6 of the Income Tax Regulations.

(d) The first required payment can be made as late as April 1 of the year following the year
the individual attains age 701/2 and must be the payment that is required for one payment
interval. The second payment need not be made until the end of the next payment interval.

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

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

(b) Death Before Required Distributions Commence. If the Owner dies before required
distributions commence, his or her entire interest will be distributed at least as rapidly
as follows:

	 	 	 	 	 

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(1) If the designated beneficiary is someone other than the Owner’s surviving
spouse, the entire interest will be distributed, starting by the end of the calendar
year following the calendar year of the Owner’s death, over the remaining life
expectancy of the designated beneficiary, with such life expectancy determined using
the age of the beneficiary as of his or her birthday in the year following the year
of the Owner’s death, or, if elected, in accordance with paragraph (b)(3) below. If
this is an inherited IRA within the meaning of Code § 408(d)(3)(C) established for
the benefit of a nonspouse designated beneficiary by a direct trustee-to-trustee
transfer from a retirement plan of a deceased individual under § 402(c)(11), then,
notwithstanding any election made by the deceased individual pursuant to the
preceding sentence, the nonspouse designated beneficiary may elect to have
distributions made under this paragraph (b)(1) if the transfer is made no later than
the end of the year following the year of death.

(2) If the Owner’s sole designated beneficiary is the Owner’s surviving spouse, the
entire interest will be distributed, starting by the end of the calendar year
following the calendar year of the Owner’s death (or by the end of the calendar year
in which the Owner would have attained age 701/2, if later), over such spouse’s life
expectancy, or, if elected, in accordance with paragraph (b)(3) below. If the
surviving spouse dies before required distributions commence to him or her, the
remaining interest will be distributed, starting by the end of the calendar year
following the calendar year of the spouse’s death, over the spouse’s designated
beneficiary’s remaining life expectancy determined using such beneficiary’s age as
of his or her birthday in the year following the death of the spouse, or, if
elected, will be distributed in accordance with paragraph (b)(3) below. If the
surviving spouse dies after required distributions commence to him or her, any
remaining interest will continue to be distributed under the Contract option chosen.

(3) If there is no designated beneficiary, or if applicable by operation of
paragraph (b)(1) or (b)(2) above, the entire interest will be distributed by the end
of the calendar year containing the fifth anniversary of the Owner’s death (or of
the spouse’s death in the case of the surviving spouse’s death before distributions
are required to begin under paragraph (b)(2) above).

(4) Life expectancy is determined using the Single Life Table in Q&A-1 of
§ 1.401(a)(9)-9 of the Income Tax Regulations. If distributions are being made to a
surviving spouse as the sole designated beneficiary, such spouse’s remaining life
expectancy for a year is the number in the Single Life Table corresponding to such
spouse’s age in the year. In all other cases, remaining life expectancy for a year
is the number in the Single Life Table corresponding to the beneficiary’s age in the
year specified in paragraph (b)(1) or (2) and reduced by 1 for each subsequent year.

(c) The “interest” in the IRA includes the amount of any outstanding rollover, transfer and
recharacterization under Q&As-7 and -8 of § 1.408-8 of the Income Tax Regulations and the
actuarial value of any other benefits provided under the IRA, such as guaranteed death
benefits.

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

	 	 	 	 	 

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

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

	10.	 	The Company shall furnish annual calendar year reports concerning the status of the annuity
and such information concerning minimum required distributions as is prescribed by the
Commissioner of Internal Revenue.
	 
	11.	 	Except to the extent Treasury regulations allow Us to offer additional Annuity Payment
Options that are acceptable to Us, only the Annuity Payment Options as described in the
Contract shall be offered unless We consent to the use of an additional option.

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

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

	12.	 	If you return the Contract within 10 days after the Contract Date, the Company will refund
the amount of your Purchase Payments, without adjustment for such items as sales commissions,
administrative expenses, and fluctuation in market value for the Valuation Period in which the
Contract is received. We reserve the right to allocate your Purchase Payment(s) to the Cash
Management Subaccount or the Money Market Portfolio, whichever is applicable, until the end of
the Right to Examine period. Thereafter, allocations will be made as You have specified and/or
shown on the Contract Data Page.
	 
	13.	 	The provisions of this Endorsement are intended to comply with the requirements of the Code
and applicable regulations for IRAs under Section 408(b) of the Code. The Company reserves
the right to amend the Contract and this Endorsement from time to time when such amendment is
necessary to assure continued qualification of the Contract as an IRA under Section 408(b) of
the Code (and any successor provision) as in effect from time to time. The Owner has the
right to refuse to accept any such amendment; however, we shall not be held liable for any tax
consequences incurred by the Owner as a result of such refusal.
	 
	14.	 	In the absence of federal legislative action, one or more of the provisions of the Code that
are reflected in this Endorsement will automatically expire on January 1, 2011. In the event
of such automatic expiration, such provisions shall cease to apply under this Endorsement.

	 	 	 	 	 

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All other terms and conditions of the Contract remain unchanged.

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

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

	 	 	 

	
	 	 
	 
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	 	5exv4wo

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

RIDER

Notwithstanding any provision in the Contract to the contrary, this Rider becomes a part of the
Contract to which it is attached. Should any provision in this Rider conflict with the Contract,
the provisions of this Rider will prevail.

EFFECTIVE DATE: [date] ¬1

Prior to the Annuity Date, We will waive the Contingent Deferred Sales Charge or Withdrawal
Charge upon the Owner’s request for full or partial surrender of the Contract Value. Such benefit
shall be available if:

	1.	 	The Owner is confined to a Nursing Home and/or Hospital for at least 60 consecutive days
while the Contract is in force;
	 
	2.	 	A surrender or partial withdrawal request and adequate proof of confinement are received by
Us either while the Owner is confined or within 90 days of the Owner’s discharge from the
Nursing Home or Hospital; and
	 
	3.	 	Confinement in a Nursing Home and/or Hospital is prescribed by a Physician and is Medically
Necessary.

A Market Value Adjustment (MVA), if any, shall not be applied to amounts withdrawn from the Fixed
Account whether such application results in a gain or a loss in the Contract Value.

This Rider may not be exercised before the expiration of 90 days from the Contract Date.

A new 60 day confinement period must be satisfied each time the Owner becomes newly confined
(whether for the same or unrelated causes), if services by a Nursing Home and/or Hospital have not
been provided for a period of at least six months. If services for related causes were provided
less than six months from current receipt of services, a new 60 day confinement need not be
satisfied.

If the Owner’s request for waiver of Contingent Deferred Sales Charges or Withdrawal Charges is
denied, the surrender proceeds will not be dispersed until the Owner is notified by Us of the
denial and provided with the opportunity to reapply for the surrender proceeds or reject the
surrender proceeds.

DEFINITIONS

For purposes of this Rider, the following definitions apply. Terms not defined in this Rider shall
have the same meaning given to them in the Contract.

	 	 	 	 	 

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“Nursing Home” means a Skilled Nursing Facility, an Intermediate Care Facility, or a
Residential Care facility. Nursing Home does not mean:

	1.	 	A home for the aged, a community living center, or a place that primarily provides
domiciliary, residency or retirement care; or
	 
	2.	 	A place owned or operated by a member of the Owner’s immediate family. Immediate family
members include the Owner’s spouse, children, parents, grandparents, grandchildren, siblings,
and in-laws.

“Skilled Nursing Facility” is a facility which:

	1.	 	Is located in the United States or its territories;
	 
	2.	 	Is licensed and operated as a Skilled Nursing Facility according to the laws of the
jurisdiction in which it is located;
	 
	3.	 	Provides skilled nursing care under the supervision of a licensed physician;
	 
	4.	 	Provides continuous 24 hours a day nursing services by or under the supervision of a
registered graduate professional nurse (R.N.); and
	 
	5.	 	Maintains a daily medical record of each patient.

“Intermediate Care Facility” is a facility which:

	1.	 	Is located in the United States or its territories;
	 
	2.	 	Is licensed and operated as an Intermediate Care Facility according to the laws of the
jurisdiction in which it is located;
	 
	3.	 	Provides continuous 24 hours a day nursing service by or under the supervision of a
registered graduate professional nurse (R.N.), or a licensed practical nurse (L.P.N.); and
	 
	4.	 	Maintains a daily medical record of each patient.

“Residential Care Facility” is a facility which:

	1.	 	Is located in the United States or its territories;
	 
	2.	 	Is licensed and operated as an Residential Care Facility according to the laws of the
jurisdiction in which it is located; and
	 
	3.	 	Provides nursing care under the supervision of a registered graduate professional nurse
(R.N.).

“Hospital” is a facility which:

	1.	 	Is located in the United States or its territories;
	 
	2.	 	Is licensed as a Hospital by the jurisdiction in which it is located;
	 
	3.	 	Is supervised by a staff of licensed physicians;
	 
	4.	 	Provides nursing services 24 hours a day by, or under the supervision of, a registered nurse
(R.N.);
	 
	5.	 	Operates primarily for the care and treatment of sick and injured persons as inpatients for a
charge; and
	 
	6.	 	Has access to medical and diagnostic facilities.

	 	 	 	 	 

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“Physician” is any person duly licensed and legally qualified to diagnose and treat sickness and
injuries. He or she must be providing services within the scope of his or her license. Physicians
do not include members of the Owner’s immediate family.

“Medically Necessary” means appropriate and consistent with the diagnosis in accord with accepted
standards of practice and which could not have been omitted without adversely affecting the
individual’s condition.

This Rider shall take effect on the Contract Date. This Rider shall terminate on the date a life
contingent annuity option is elected, since Contract Value will cease to be available on that date.

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

	 	 	 	 	 

	 
	 		 	 
	 
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