Nationwide Distribution Request

PaCArSEtNiUcMiBpERa: _n___t__D___i_s__t__r__i_bution Request

?

Nationwide Retirement Plans ? Phone: 1-877-588-6724 ? Fax: 1-877-NF401ks (1-877-634-0157)

Purpose of Form

This form is to be used for participant/beneficiary level withdrawal types listed below in Section 2, if available in your plan. Financial hardship requests are submitted on a specific Financial Hardship withdrawal form. This form is to be used for participants of plans where Nationwide serves as third party administrator.

Case Information

Case Number

_ Case Name

Section 1 Participant Information

_ Participant Name

Social Security Number (###-##-####) Date of Birth (MM/DD/YYYY)

Date of Hire (MM/DD/YYYY)

Home Address

City

State

ZIP Code

Telephone Number Marital Status:

Single

Married

Divorced

Widowed

Section 2 Reason for Distribution

Check the option that applies: Termination of Employment* Attainment of Normal Retirement Age

Withdrawal of Rollover Contributions** Withdrawal of After-Tax Voluntary Contributions**

Plan Termination

In-Service Withdrawal**

Total and Permanent Disability

Reservist Called to Active Military Service Distribution

Death (for beneficiaries only - attach a certified copy of the death certificate)

* Transferring from one employer to another within the same controlled group does not constitute termination of employment and is not a distributable event.

** If permitted under the terms of the Plan Document

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Section 3 Cash Distribution

ACCOUNT NOTE: If checking or savings is not chosen, we will default to checking. If

any information is missing or incorrect a check will be issued.

CASE NUMBER:

Cash Payment -This will be a taxable distribution (with the possible exception of Roth or after-tax contributions) and taxes will be withheld as required by law. Additional Federal or State withholding can be requested in Section 7.

Total distribution of vested account balance(s).

Partial distribution (if allowed) of my vested account balance(s) in the amount of:

$

_

GROSS (before taxes) OR

NET (after taxes)

Combination of Cash Payment and Direct Rollover - Any portion of this payout that is paid directly to me will be a taxable distribution (with the possible exception of Roth or after-tax contributions) and taxes will be withheld as required by law. Additional Federal or State withholding can be requested in Section 7.

I request a cash payment of $

.

GROSS (before taxes) OR

NET (after taxes)

(With the remaining vested balance being directly rolled over per the rollover instructions).

CashPayment Method:

Send check by first class mail.

Send check overnight by UPS. I understand that standard processing time still applies and there is an additional $25 fee for the UPS overnight shipping charges that will be deducted from my account.

Direct Deposit by ACH.

Type of Account:

Checking

OR

Savings Account

_ Bank Name

_ City, State, and Zip Code

_ ABANumber

_ Account Number

_ Name on Account

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Section 4 Direct Rollover

Distribution Direction

WIRE and ACH NOTE: Wires and ACH are not

available payment options for rollovers.

ROTH ACCOUNT NOTE: When both

ROTH and pre-tax funds are being rolled over, separate account

numbers must be provided.

CASE NUMBER:

Direct Rollover ? A check will be sent directly to the custodian/trustee indicated below. Be sure your plan/IRA allows rollovers from these sources.

Please choose the appropriate direct rollover option(s) below: Rollover of Pre-tax vested balance to a Traditional IRA

Rollover of Pre-tax vested balance to another eligible retirement plan.

Rollover of Pre-tax vested balance to a ROTH IRA ?There is no tax free treatment for a distribution rolled over to a Roth IRA. This distribution will be reported as taxable income for the year distributed. Nationwide will not withhold Federal or State taxes unless specifically requested in Section 6.

Please choose the appropriate direct rollover option(s) below if you have ROTH contributions:

Rollover of ROTH 401(k)/403(b) account balance to a ROTH IRA.

Rollover of ROTH deferrals to another 401(k), 403(b) or governmental 457 plan's ROTH elective deferral account

This direct rollover is for (please check one): Total Vested Balance OR

Specific Amount $

Account Information:

Check Payable to Trustee/Custodian Traditional (Pre-Tax) Account Number

_ ROTH Account (if applicable)

Address of Trustee/Custodian

City

State

Zip Code

Payment Method: Send check by first class mail.

Send check overnight by UPS. I understand that standard processing time still applies and there is an additional $25 fee for the UPS overnight shipping charges which will be deducted from my account.

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Section 5 Annuity Purchase

CASE NUMBER: This option is not available to all plans. To verify available options under your plan, please contact the plan sponsor.

Life annuity with 60, 120, or 240 monthly payments guaranteed. Annuity for life, with 50%, 66 2/3 %, 75%, or 100% survivor annuity. Upon my death paid to:

Name of Joint Annuitant

Joint Annuitant Date of Birth (MM/DD/YYYY)

Annuity with payments over

_ years.

Other:

Section 6 Federal and

State Tax Withholding

Note: Do not complete this section if this is a rollover to another eligible retirement plan or IRA.

If your benefit is paid directly to you and is an eligible rollover distribution, please note that a mandatory 20% Federal withholding and any mandatory state withholding will apply to the taxable portion of your distribution prior to receiving the funds.

Federal Taxes: Please select one of the options below, only if you are not requesting a rollover to another eligible retirement plan or IRA.

Please withhold only the mandatory Federal tax rate from my distribution (20%). Note: This will be the default if no option is selected.

OR

I wish to withhold an amount greater than the mandatory 20% Federal tax rate from my distribution. Note: The amount designated below must be greater than 20%

_% or

$

State Taxes: Indicate below the state taxes to be withheld from your distribution.

Note: If you reside in a state that requires mandatory taxes, the applicable tax rate will be withheld even if you enter a lesser amount or leave this section blank. Otherwise, we will withhold taxes as directed below.

____________% or ____________$ for the State of _____________________

Note: If you do not have enough taxes withheld, you may be responsible for payments of estimated income tax and penalties. For further details, see the attached Special Tax Notice regarding Plan Payments.

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Section 7 Beneficiary Information for Death Benefits

NOTE: If there are multiple beneficiaries then each beneficiary

must complete a separate form.

Section 8 Participant/ Beneficiary Authorization

CASE NUMBER:

_____________________________________________________________________

Type or Print Payee Full Name

Payee Social Security Number

_____________________________________________________________________

Payee Home Address (number and street or rural route)

Phone Number

_____________________________________________________________________ City, State and Zip Code _____________________________

Payee Date of Birth (MM/DD/YYYY)

Under penalties of perjury, I certify that: 1. The number shown 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 by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS 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.

By signing below, I hereby acknowledge the following information: 1. Rollover contributions to governmental 457(b) plans that originated from qualified plans, IRAs and 403(b) plans are subject to the early distribution tax that applies to 401 plans unless an exception applicable to 401 plans applies. 2. Rollover contributions are subject to the Required Minimum Distribution (RMD) rules of the plan they are rolled into, not the plan or IRA from which they came.

Federal income tax will be withheld from your payments as required by the Internal Revenue Code. If you select a lump sum or systematic withdrawal lasting less than 10 years 20% of the taxable portion of the distribution paid to you will be withheld for federal income taxes. State taxes will be withheld where applicable. State and federal taxes withheld will be reported on a form 1099-R.

The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding.

I consent to a distribution as elected above. I understand that the terms of the plan document will control the amount and timing of any payment from the plan. Further, I certify that I have read and received the attached Special Tax Notice Regarding Plan Payments. If I elect to receive this distribution before the end of the 30 day minimum notice period, my signature on this election form shall constitute a waiver of my rights to the 30 day notice requirement, if applicable.

I hereby authorize the above elected benefit and attest to the accuracy of the information.

I acknowledge that a withdrawal fee may apply and will be deducted from my account.*

Also, I understand that once submitted this election is final.

Participant/Beneficiary Signature

Dated (MM/DD/YYYY)

*The amount of the fee is stipulated in the service agreement for the plan and may be obtained from your employer.

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