Participant Withdrawal/Direct Rollover Request Private Sector Operations

Participant Withdrawal/Direct Rollover Request Private Sector Operations

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Phone: 1-800-548-6436 ? Fax: 1-877-634-0157 ?

NOTE: Do NOT use this form for distributions from 457(b) Tax-Exempt or Non-Qualified (Non-Governmental) Deferred Compensation Plans. Please use the 457(b) Tax-Exempt or Non-Qualified (Non-Governmental) Deferred Compensation.

1. Purpose

To be completed by the Administrator or Plan Sponsor. Use this form when requesting a distribution from traditional or Roth sources of money for participant accounting or investment only plans when Nationwide is designated the payor, and responsible for tax reporting the distribution.

2. Case Information

Case Number: Case Name:

Does this case include multiple fixed contracts?

c Yes c No (If Yes, answer the next question)

Does the de minimis policy apply to this withdrawal?

c Yes c No (If No, complete Attachment B)

3. Participant Information (all fields required)

Name: SSN:

Street Address:

City: State: ZIP:

Phone: Email:

c Participant has assets in a Self Directed Brokerage account

Date of Birth:

NOTE: Tax document will be mailed to the address specified unless alternate payee or beneficiary information provided.

4. Payee Information

Total number of Payees:

(Use a separate form for each payee)

Distribution Reason:

c Termination of Employment

c Disability

c Withdrawal of Rollover Contributions

c Death

c Hardship Withdrawal c Withdrawal of After-Tax Voluntary Contributions

c Required Minimum Distribution c Loan Withdrawal

c Reservist Called to Active Military Service Distribution

c In-Service Withdrawal

c Plan Termination (requires Asset Transfer Request form)

c Other:

Distribution is for: c Participant c Beneficiary

Beneficiary Information:

Name: SSN:

Street Address:

City: State: ZIP:

Payment Method: c Direct Payment c Direct Rollover to Other Eligible Plan or IRA

c Repetitive Payments - Frequency: c Monthly c Quarterly c Semi-Annually c Annually

Beginning on date (required):

(mm/dd) (must be between the 1st and 25th)

NOTE: repetitive payments will be processed within 5 business days of the date selected and will continue until your account is exhausted or written direction is received to stop payments.

To cancel payments, email your Client Service Representative or call 800-548-6436.

For SDB Accounts: c Liquidate 100% of SDB account back to Nationwide core account. ACTION REQUIRED: In accordance with the Plan Sponsor agreements, prior to the completion of the withdrawal/direct rollover request, the Participant must liquidate 100% of their SDBA and exchange the assets back to their core account held at Nationwide. Failure to complete this process will delay the withdrawal. NOTE: Liquidations may incur fees as described in the Plan Sponsor agreements with Nationwide and the SDBA provider.

c IN KIND transfer 100% of SDB account to (receiving company): NOTE: $100 IN KIND transfer fee applies per account

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4. Payee Information (continued)

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Financial Institution Information:

Payee Name: FBO:

Account #: Account # (Roth):

Street Address:

City: State: ZIP:

5. Account Information

Non-Resident Alien: Taxable distributions to non-resident aliens are subject to 30% withholding unless a valid IRS form W-8BEN containing an ITIN (individual taxpayer identification number) is submitted to claim a reduced rate or withholding exemption that is available under a U.S. income tax treaty.

Puerto Rico Distributions: Is the taxpayer a resident of Puerto Rico? c Yes c No

Traditional Sources (1-20)

F Total OR c Partial Distribution NOTE: If total distribution is marked

above, and fund/source & amount are left blank we will process from all funds/ sources and 100% of balance.

If partial is marked, fund/source/ amount must be completed in order to be processed.

Fund

Source

Amount

$ Unit % ccc ccc ccc ccc

Forfeit c Yes c No c Yes c No c Yes c No c Yes c No

Total:

IRS Distribution Code (select one): c 1 - Premature Participant Distribution (Under 59?) c 2 - Premature with exceptions Distributions c 4 - Death Benefit c 7 - Standard Distribution (Over 59?) c G - Rollover c 4G - Death Benefit Rollover c Other:

Outstanding Loan (additional reportable): $ Distribution Code for Outstanding Loan:

Employee Contributions (Non-Taxable): $

Roth Sources (21-24)

c Total OR c Partial Distribution NOTE: If total distribution is marked

above, and fund/source & amount are left blank we will process from all funds/ sources and 100% of balance.

If partial is marked, fund/source/ amount must be completed in order to be processed.

Fund

Source 21 22 23 24

Amount

$ Unit % ccc

1st Yr. of Desig. CN.

EE Contrib. Amount

$

ccc

$

ccc

$

ccc

$

Total:

IRS Distribution Code (select one): c 1B - Premature Participant Distribution (Under 59?) c 7B - Standard Distribution (Over 59?) c 4B - Death Benefit c BG - Roth to Roth Rollover c H - Roth 401(k) to Roth IRA

Outstanding Loan (additional reportable): $ Distribution Code for Outstanding Loan:

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6. Tax Withholding

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Federal income tax withholding:

Withholding election for direct payments and systematic payments lasting less than 10 years:

There is a mandatory 20% withholding for federal income taxes (Note: Hardships, RMDs and Pre-tax to Roth Rollovers have a mandatory 10% withholding for federal income taxes). Roth distributions will have the same taxes withheld unless you have attained an age of at least 59? and your Roth account has been established for a minimum of 5 years. You may elect to withhold an additional percentage. If you wish to do so, please indicate this below.

F I wish to have a different percentage of Federal Income Tax withheld. At time of submission a W-4R Federal Tax Withholding Form is required. The current Form W-4R form can be found on the IRS website at forms-pubs-search.

NOTE: If we don't receive the Form W-4R, Nationwide will default to withholding taxes based on the current Internal Revenue Code (IRC) withholding rules.

Withholding eletion for systematic payments (including RMD payments) lasting 10 years or more:

For systematic payments lasting 10 years or more, federal income taxes are withheld at the current IRC withholding rules. For RMD payments, federal income taxes are withheld at the current default rate of 10% unless you elect otherwise. If you wish a different withholding percentage, please select one of the options listed below.

F I elect to opt-out of federal income tax withholding; 0% withholding

F I wish to have a different percentage of Federal Income Tax withheld. At time of submission a W-4P Federal Tax Withholding Form (systematic payments lasting 10 years or more) or the Form W-4R Federal Tax Withholding Form (RMD) is required. The current Form W-4P and Form W-4R can be found on the IRS website at forms-pubs-search.

NOTE: If we don't receive the Form W-4P or W-4R, Nationwide will default to withholding taxes based on the current IRC withholding rules.

State income tax withholding: Taxes will be automatically withheld if you are a resident in a state that mandates state income tax withholding. If you would like to adjust your state taxes, please completed and attach a state tax withholding form. These forms can be obtained form the state website, Nationwide does not supply these forms.

7. Fees

CDSC:

Was the Participant ever an owner/officer? c No c Yes, Complete CDSC/Term Charge sheet

In-Kind:

A $100 fee applies to each in-kind transfer distribution.

Investment Only:

Fees will be taken in addition to the withdrawal amount specified.

Participant Accounting: Fees will be netted from the distribution when taking 100% of the participant's account.

Redemption Fee for Some of the funds in this plan may have redemption fee policies. This transaction may be subject Participant Accounting: to redemption fees. Please review the Trading Policy List for more details.

PPA/TPA Fee:

Does a PPA/TPA Withdrawal Fee apply? Show PPA/TPA Fees on Check?

If Yes, Amount: $ c No c Yes (if blank, No is assumed)

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8. Payment Method

c Wire 1, 2 c ACH Checking 1 c ACH Savings 1

Receiving Bank Name:

City: State: ZIP:

ABA (Routing)#:

Account #:

c Check 1

Mail to: c Plan Administrator c Participant c Payee c Plan Sponsor c Other (enter address below)

Street Address:

City: State: ZIP:

Shipping Method:

c U.S. Mail

c UPS

c FedEx

UPS/FedEx-Account #:

If FedEx is selected, you must provide the package recipient's phone number:

UPS/FedEx Options: c Next Day by 10:30 am

c 2nd Business Day by 10:30 am

c Next Day by 3:00 pm

c 2nd Business Day by 4:30 pm

1 If no method is indicated, Nationwide will default to mailing a check to the payee via US Mail. NOTE: a prepaid card is not a valid payment method.

2 If Repetitive Payments was selected in Section 4, Wire is NOT an option for payment method. ACH or Check only.

9. Authorization

As authorized representative, by signing below I certify that I have received the proper documentation and have verified the taxpayer identification number for the participant identified above is correct.

Authorized Representative/Administration Firm:

Name (Please Print):

Signature: Date: NOTE: electronic or stamped signatures are not permitted.

NOTE: To expedite the processing of this request please email this completed form to nwforms@. This will result in this request being automatically fed into our work-flow process.

Nationwide and the Nationwide N and Eagle are service marks of Nationwide Mutual Insurance Company. ?2023 Nationwide

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