It s decision time. Determine the future of your Nationwide annuity and Capital Preservation Plus Lifetime Income Years ago, you and your investment professional made the decision to purchase a Nationwide annuity with the Capital Preservation Plus Lifetime Income (CPPLI) rider. It was a smart choice then, and it s still a smart one today. But the original time frame you selected for the rider is set to expire, and you have a decision to make. Helping you understand your choices. As you ll see from the enclosed forms, you have several available options. We ve notified your investment professional of your upcoming decision, and he or she is prepared to help you understand your options. We encourage you to contact your investment professional to review these materials before making any decisions. One choice is to simply renew your CPPLI rider. If the rider still makes sense for you and meets your retirement goals, we encourage you to continue taking advantage of it. Here s why: CPPLI protects your principal investment regardless of market activity something few other products can offer today CPPLI is no longer available for purchase; you re part of a select group of customers who can still take advantage of its benefits Even though the CPPLI rider is about to mature, your annuity contract can remain at Nationwide as long as you d like. But, if you choose to surrender your contract, please keep in mind that fees will apply if your annuity is still within its surrender charge period. We re here to help. After consulting with your investment professional, we understand you may still have some questions about your contract or the options presented here. Feel free to contact us at 1-800-848-6331. We re available to assist you Monday through Friday from 8 a.m. to 8 p.m. Eastern time. Annuities are underwritten by Nationwide Life Insurance Company or Nationwide Life and Annuity Insurance Company, Columbus, Ohio. The general distributor is Nationwide Investment Services Corporation, member FINRA. In MI only: Nationwide Investment Svcs. Corporation. Nationwide, Nationwide Financial and the Nationwide framemark are service marks of Nationwide Mutual Insurance Company. Capital Preservation Plus Lifetime Income is a service mark of Nationwide Life Insurance Company. 2011, 2014 Nationwide Financial Services, Inc. NFM-9125AO.2 (08/14)
(For contracts moving from Capital Preservation Plus Lifetime Income to Enhanced Capital Preservation Plus Lifetime Income, Continuing with 6% Immediate Withdrawal Option, or Entering Lifetime Income Phase) Mail to: Nationwide Life Insurance Company and Nationwide Life and Annuity Insurance Company Individual Annuities, P.O. Box 182021, Columbus, Ohio, 43218-2021, 800-848-6331, Fax to: 888-634-4472, nationwide.com Page 1 of 8 1. General Information Please print. Existing Contract Number: (Required) Owner s First/Last Name: Owner s Address: City/State/ZIP: Social Security Number: (Important) Telephone Number: ( ) Want a transaction status? Provide an E-mail address and a status will be sent upon processing. E-mail Address: 2. Directions for Completing this Form Below are the options that are available to you upon maturity of your Capital Preservation Plus Lifetime Income (CPPLI) rider. Not all sections will need to be completed. Please read each section carefully to determine the option that best fits your needs. Preservation Phase for a 10 Year Term - Section 3 This option allows you to renew into a new Preservation Phase for 10 years Continue 6% Immediate Withdrawal Phase - Section 4 This option is only available for client s who have already selected the 6% Immediate Withdrawal and are unable to elect the Lifetime Income Phase Entering the Lifetime Income Phase - Section 5 This will allow you to start withdrawals immediately or delay them until a later date. The annual eligible withdrawal amount will be based on your age at the time you start withdrawals Available Funding Options for Continuing 6% Immediate Withdrawal OR Entering the Lifetime Income Withdrawal Phase - Section 6 This section must be completed if you are electing to either continue your 6% Immediate Withdrawal or are electing to enter into the Lifetime Income Phase Lifetime Income Phase Withdrawal Option - Section 7 The program information is required to be completed if you made an election from Section 5b. It provides Nationwide with your payment information Satisfying your Required Minimum Distribution (RMD) - Section 8 This section allows you to satisfy RMD with Lifetime Income Termination - Section 12 This section will terminate your CPPLI rider and any benefits that go along with this rider. At termination, variable funds, including the money market fund, are subject to market risk and no longer have a guarantee minimum value Signatures - Section 14 This section must be complete in order to process your election
Page 2 of 8 3. Election of Preservation Phase Election of Enhanced Capital Preservation Plus Lifetime Income (ECPPLI) Select one fund from Box A or Nationwide Custom Portfolio from Box B. A 10 Year Term - Investment Option B 100% of the variable money in the contract (Select only one.) will be allocated to option elected. American Funds NVIT Asset Allocation Fund Nationwide Custom Portfolio American Funds Option (34% American Funds NVIT Growth-Income Fund, 33% American Funds NVIT Asset Allocation Fund, 33% American Funds NVIT Bond Fund) 3 Fidelity VIP Freedom Fund 2010 Portfolio 2 Fidelity VIP Freedom Fund 2020 Portfolio 2 Fidelity VIP Freedom Fund 2030 Portfolio 2 NVIT Cardinal SM Aggressive Fund 1 NVIT Cardinal SM Balanced Fund 1 NVIT Cardinal SM Capital Appreciation Fund 1 NVIT Cardinal SM Conservative Fund 1 NVIT Cardinal SM Managed Growth & Income Fund 3 NVIT Cardinal SM Managed Growth Fund 3 NVIT Cardinal SM Moderate Fund 1 NVIT Cardinal SM Moderately Aggressive Fund 1 NVIT Cardinal SM Moderately Conservative Fund 1 NVIT Investor Dest. Aggressive Fund NVIT Investor Dest. Balanced Fund NVIT Investor Dest. Capital Appreciation Fund NVIT Investor Dest. Conservative Fund NVIT Investor Dest. Managed Growth & Income Fund 3 NVIT Investor Dest. Managed Growth Fund 3 NVIT Investor Dest. Moderate Fund NVIT Investor Dest. Moderately Aggressive Fund NVIT Investor Dest. Moderately Conservative Fund NVIT Managed American Funds Asset Allocation Fund 3 STOP Nationwide Custom Portfolio requires submission of a NEW Custom Portfolio form in addition to this form. Additional information: Subsequent payments and loans are not permitted Enrollment in the Enhanced CPPLI Program allows you to move between available NVIT Cardinal Asset Allocation Funds, Nationwide Investor Destinations Funds and Custom Portfolio models as long as you remain with the same Risk Tolerance Model For Contracts issued in New York in the Preservation Phase, you must be 79 years of age or younger when you elect either the ECPPLI program or the ECPPLI program with Nationwide Custom Portfolio 1 Not available with America s Horizon Product 2 Not available with Wells Fargo Gold 3 Not available with Compass All American Gold, America s Horizon, Key All American Gold, and Waddell and Reed Select Preferred OR
Page 3 of 8 4. Election to Continue 6% Immediate Withdrawal Election to Continue Current 6% Immediate Withdrawal Benefit Phase This option is only available for client s who have already selected the 6% Immediate Withdrawal Benefit Remember, you must select funding options from Section 6 before proceeding to sign and return this form If Nationwide does not receive instructions from you by your maturity date, we will assume that your intent is to terminate the CPPLI rider. When this option is terminated, you will lose the value of the remaining immediate withdrawal base and the guarantee associated with these payments will be discontinued 5. Election to Enter Lifetime Income Phase of CPPLI Select only one Option from Section 5a or 5b. 5a. Election to Enter Lifetime Income Phase, but Delay Scheduled Withdrawals at this time Remember, you must select funding options from Section 6 before proceeding to sign and return this form. Please contact Nationwide at 800-848-6331 when you are ready to begin Lifetime Income withdrawals and request the Capital Preservation Plus Lifetime Income (CPPLI) Withdrawal Administrative Form Your guaranteed Lifetime Income percentage is not calculated until the first withdrawal is made Subsequent payments and loans are not permitted 5b. Election to Enter Lifetime Income Phase and Start Scheduled Withdrawals after Maturity Date Remember, you must select funding options from Section 6 before you proceed to the Lifetime Income Phase Withdrawal Option Section 7 for your Scheduled Withdrawal Request. 6. Available Funding Options for Continuing 6% Immediate Withdrawal OR Entering the Lifetime Income Withdrawal Phase Must be completed for Sections 4, 5a, or 5b if elected. Select Funding Options from Either Box A, Box B, or Box C A Whole percentages only. Must add up to 100%. = 100% % NVIT Investor Dest. Conservative Fund % NVIT Investor Dest. Moderately Conservative Fund % NVIT Investor Dest. Balanced Fund % NVIT Investor Dest. Moderate Fund % NVIT Cardinal SM Conservative Fund % NVIT Cardinal SM Moderately Conservative Fund % NVIT Cardinal SM Balanced Fund % NVIT Cardinal SM Moderate Fund OR B C Elect one option only. 100% of the variable money in the contract will be allocated to option elected. Nationwide Custom Portfolio Nationwide Custom Portfolio requires submission STOP of a NEW Custom Portfolio form in addition to this form. Risk Tolerance availability is limited to: Conservative, Moderately Conservative, Balanced, and Moderate. Elect one option only. 100% of the variable money in the contract will be allocated to option elected. American Funds Option (34% American Funds NVIT Growth-Income Fund, 33% American Funds NVIT Asset Allocation Fund, 33% American Funds NVIT Bond Fund)
Page 4 of 8 7. Lifetime Income Phase Scheduled Withdrawal Options! If no option is selected, Nationwide defaults to the Lifetime Income maximum allowable amount option. Complete only if you have elected to enter the Lifetime Income Phase and start scheduled withdrawals. Only one option may be selected from 7a, 7b, or 7c. 7a. Maximum Allowable Amount Per Year 1 This option will recalculate the amount of your regularly scheduled payment in the event you make any additional withdrawals (processed outside of this scheduled withdrawal). If the start date is not the beginning of your Lifetime Income Withdrawal Phase, your maximum amount will be divided by the remaining elected frequency periods. This may result in a change of your scheduled amount on your next Lifetime Income Withdrawal anniversary If an additional withdrawal is taken outside of the scheduled withdrawal, the amount will be adjusted for the next scheduled withdrawal(s) If an additional withdrawal results in exceeding your maximum allowable amount, your scheduled withdrawal amount will stop until the first scheduled withdrawal after your next Lifetime Income anniversary 7b. Level Amount Per Year 1 This option allows your scheduled withdrawal to remain the same until your next Lifetime Income Withdrawal Anniversary year even if you make additional withdrawals. This may result in a change to your Lifetime Income Withdrawal base. The level amount is calculated by taking the Lifetime Income Withdrawal base times the withdrawal percent, divided by the number of periods in the selected frequency (12 for monthly, 4 for quarterly, 2 for semi annual, and 1 for annual), regardless of when withdrawals are scheduled to begin Any additional withdrawals outside of your scheduled withdrawal made will not change this amount Nationwide can recalculate the withdrawal amount upon written request The scheduled withdrawal amount will automatically adjust after each Lifetime Income Withdrawal anniversary if your benefit base amount has changed 7c. Specific Amount: $,,. (May result in a reduction of your Lifetime Income Withdrawal Base) This amount will not be changed unless Nationwide is notified in writing. Net Amount - after taxes and charges Gross Amount - before taxes and charges (Default) 1 Calculated by Nationwide
Page 5 of 8 8. Satisfying your Required Minimum Distribution (RMD)! Proceed to Section 9 for Non-Qualified annuity and Roth IRA contracts. This section is applicable for IRA, 403(b), 401 contracts and when the contract owner(s) has reached 70 ½ years or older. The Nationwide Lifetime Income Phase of CPPLI offers the greater of: 1. The RMD amount for the calendar year at the beginning of the Lifetime Income Withdrawal anniversary year or 2. Annual Lifetime Income amount To take advantage of the greater benefit amount, your withdrawal needs to be set up to run annually, the day after your Lifetime Income Withdrawal anniversary The withdrawal will be set up with Max Option. Please refer to Page 4, Section 7 for details Since the RMD amount can change annually, Nationwide can only insure the RMD amount will be satisfied using the above setup arrangement The RMD amount for subsequent calendar years will not be available without decreasing the Lifetime Withdrawal base, until after a new Lifetime Income Withdrawal anniversary has been reached for your contract Any amounts withdrawn that exceed this calculation may result in a reduction of the Lifetime Income Withdrawal base The RMD amount available is calculated from this contract only; additional policies at Nationwide or other carriers will not be figured into the RMD amount For contracts with a Lifetime Income Withdrawal anniversary beginning on December 31st, the scheduled withdrawal will run for the annual amount on December 31st each subsequent year or the last business day of the year Other withdrawal frequencies are available but Nationwide will not guarantee that the Lifetime Income Withdrawal base will not be reduced or RMD amount will be satisfied. For any other frequency that is not annual, you must also select Maximum Allowable or Level Amount in Section 7 8a. Satisfy my RMD Please select only one option. 1. RMD using my Lifetime Income My current year RMD has already been satisfied (sign, date and return this form to Nationwide) Satisfy my current and future years RMD Current year RMD has already been satisfied, process future years only Satisfy only my current year RMD 2. RMD only If you elect to take your RMD during the Lifetime Income Phase, you may not be taking full financial advantage of the L.inc Rider. My current year RMD has already been satisfied (sign, date and return this form to Nationwide) Satisfy my current and future years RMD Current year RMD has already been satisfied, process future years only Satisfy only my current year RMD Specific Amount: $ 8b. Satisfy my RMD during the preservation phase of CPPLI I elect to use a frequency other than annually Note: We do not guarantee the Lifetime withdrawal Benefit Base will not be reduced. Withdrawals in excess of the guaranteed withdrawal amount, called excess withdrawals, may result in a permanent reduction in future guaranteed withdrawal amounts. Please refer to your product prospectus for additional information. If you would like to make an excess withdrawal and are uncertain how an excess withdrawal will reduce your future withdrawal amounts, you may contact Nationwide prior to requesting the withdrawal to obtain a personalized, transaction-specific calculation showing the effect of the excess withdrawal. Please continue to Section 9.
Page 6 of 8 9. Withdrawal Information Withdrawal Frequency Please select one option.! If this section is blank, Nationwide defaults to monthly withdrawals. RMD withdrawals will default to annual Annually Semi-Annually Quarterly Monthly withdrawals. Start Date / / MM DD YYYY 10. Tax Withholding and Method of Payment Information Must be completed for all withdrawals.! 10a. Tax Withholding Do not withhold taxes Withhold federal taxes % Withhold state taxes % If this section is blank, we will default to For state withholding, please list your state of residence 1 : withholding taxes. 1 If state income tax is withheld, as required by specific states and their regulations, Nationwide will round the dollar amount up to the next whole dollar. To avoid mandatory state withholding, for those states that require it, you Must provide a completed state tax form. These forms can be obtained from the State web site, Nationwide does not supply these forms. 10b. Method of Payment Please select only one option. Fastest method to receive funds! Use account information on file List last four (4) digits of the account number: OR Direct Deposit (A voided check is required for direct deposit. Deposit slips are not acceptable.) Financial institution Name: Financial institution Phone Number: ( ) By electing direct deposit I am authorizing Nationwide to credit the account that I have identified on this form. You must attach a voided check if depositing to your checking account. If depositing to your savings account, a letter from your financial institution, on bank letterhead stating your name, type of account, account number, routing number (ABA), that is signed by a bank employee will be required. Note: If no voided check (or letter from your bank/financial institution) is included, a check will automatically be mailed to the Owner s address of record unless an alternate address is provided below. Check to Owner Check to Alternate Payee (Please fill out the following fields) Check payable to/name: Address: City, State, ZIP:
Page 7 of 8 11. Important Information 11a. General Information Your check will normally be sent the day after the withdrawal date. It typically takes 4-5 business days to receive your check and 2-3 business days for direct deposit. Please take this into consideration when selecting your withdrawal date. If direct deposit is selected a voided check or letter from the financial institution that shows your ABA (i.e. Transit routing number) and account numbers will be required. Contingent Deferred Sales Charges may be deducted from these distributions as outlined in the Contract. This request will remain in effect until cancelled in writing. For contracts with the Extra Value Option, a forfeiture may occur if the penalty free amount is exceeded. You are liable for all federal and state income tax withholdings on the taxable portion of the withdrawal. You may also be subject to tax penalties under the estimated tax payment rules if your payments of estimated tax withholding, if any, are not sufficient. A 10% federal tax penalty may be assessed to withdrawals on the annuity contract if the contract owner is under 59 ½. Generally, withdrawals from 403(b) and Qualified Plans will be subject to a 20% Federal Income Tax withholding unless the withdrawal is not eligible for a rollover. Withholding with respect to 403(b) and qualified plans is 20%, if the distribution is an eligible rollover distribution (ERD). If the distribution is not an ERD, then withholding is elective. Please consult with your tax advisor on these matters. Withdrawals in excess of the guaranteed withdrawal amount, called excess withdrawals, may result in a permanent reduction in future guaranteed withdrawal amounts. Please refer to your product prospectus for additional information. If you would like to make an excess withdrawal and are uncertain how an excess withdrawal will reduce your future withdrawal amounts, you may contact Nationwide prior to requesting the withdrawal to obtain a personalized, transaction-specific calculation showing the effect of the excess withdrawal. If your contract is issued as part of a partial 1035 exchange that is completed on or after October 24, 2011, and a distribution or surrender was made from either contract within 180 days after the exchange, the IRS may treat the distribution or surrender either as (a) a distribution from the proceeds transferred in the partial 1035 exchange, which would be taxable to the extent that there was income in the original contract as it was constituted immediately prior to the partial 1035 exchange; or (b) a distribution from the contract as it was constituted at the time of the distribution or surrender. Depending on your specific circumstances, the taxable amounts determined under (a) and (b) could be different. The 180 day rule does not apply to an annuitization of either contract for a period of 10 or more years or during one or more lives. In addition to any income taxation, the distribution is also subject to the 10% early distribution penalty unless the distribution meets certain defined exceptions. Because the IRS has not issued guidance as to what factors or circumstances will determine the ultimate tax treatment of a distribution or surrender from either contract within 180 days after the exchange, Nationwide will tax report the distribution as a distribution from the actual contract from which it originated. Please consult your prospectus for more information and discuss any tax consequences concerning any contemplated transactions with a professional tax advisor. Any withdrawals taken in the lifetime income phase lock in the withdrawal percentage available (based on your age at the time of the first withdrawal). At the time of first withdrawal the Lifetime Income Withdrawal base is calculated and will not change unless excess withdrawals or a reset is elected. Withdrawals will be taken from the variable funds proportionally. Excess withdrawals that reduce the Lifetime Income Withdrawal base to zero will cause Nationwide to discontinue any scheduled withdrawals. The available withdrawal amount is based on the anniversary date of the election of the Lifetime Income phase, not the calendar year. Due to Lifetime Income Withdrawal anniversary processing the start date for scheduled withdrawals can not be set up to process on the Lifetime Income Withdrawal anniversary. Any requests selecting this date will be set up to run on the next business day. Once you become subject to Required Minimum Distribution (RMD), you may need to change your scheduled withdrawal in order to satisfy IRS guidelines regarding RMD. Disclosures Continue on Page 8.
Page 8 of 8 11. Important Information Continued. 11b. Lifetime Income Withdrawal for Required Minimum Distribution I understand that a Contingent Deferred Sales charge may be deducted for withdrawals in excess of Required Minimum Distributions (RMD) for this contract. A mandatory 20% withholding on any distribution amount in excess of your RMD will apply if the excess qualifies as an eligible rollover distribution (ERD) qualified 401 and 403(b) contracts. Once withholding has been taken on a distribution, it cannot be reversed; future distributions can be changed. The contract owner is responsible to make sure all RMD amounts are withdrawn timely to comply with IRS guidelines each year. Withdrawals cannot be fund directed. Withdrawals will be taken from the variable funds proportionally. 12. Terminate Capital Preservation Plus Lifetime Income Please select only one. 12a. Termination of Capital Preservation Plus Lifetime Income Any funds in a Guaranteed Term Option or Target Term Option (GTO/TTO) will be moved to the Money Market Fund. Credit of principle will be deposited to the money market fund, if applicable. At termination, variable funds, including the money market fund, are subject to market risk and no longer have a guarantee minimum value. If you have funds in an asset allocation model, your contract will be rebalanced including the Money Market Fund the day after your rider maturity date, as described in the contract prospectus. OR 12b. Termination of Capital Preservation Plus Lifetime Income and move all variable funds including GTO and TTO funds to the money market sub-account 13. Taxpayer ID Certification I certify that under penalties of perjury that: 1) The Taxpayer Identification Number or Social Security Number listed on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and 2) I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) The Internal Revenue Service has notified me that I am no longer subject to backup withholding, and 3) I am a U.S. citizen or other U.S. person, and 4) The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct. You must cross out item (2) if you have been notified by the IRS that you are currently subject to backup withholding because of failure to report interest or dividends on your tax return. 14. Signatures Request must be signed to be complete. The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding. Contract Owner: SSN: - - (Required) Signature: X Date: / / Joint Owner: (If applicable, Please print) Signature: X Date: / /