Service Forms

File Name
Updated
Investment Instructions -Monument Advisor (PDF) 02/01/2023
Deferred Annuitization Election Form (PDF) 01/27/2023
IRS W-4P Form (PDF) 01/27/2023
Payout Beneficiary Claim Form (PDF) 01/27/2023
Deferred Annuitization Election Form (PDF) 01/27/2023
Deferred Annuitization Election Form (PDF) 01/27/2023
IRS W-4P Form (PDF) 01/27/2023
IRS W-4P Form (PDF) 01/27/2023
IRS W-4P Form (PDF) 01/27/2023
Payout Beneficiary Claim Form (PDF) 01/27/2023
Investment Instructions - Monument Advisor Select (PDF) 12/07/2022
Contract Owner Withdrawal for Non-Qualified Contracts (PDF) 11/18/2022
Contract Owner Withdrawal for Qualified Contracts (PDF) 11/18/2022
TSA Hardship Withdrawal Request - VA 107 (PDF) 11/18/2022
Advisor Authorization Agreement (PDF) 09/09/2022
Advisor Fee Instructions (PDF) 09/09/2022
Agent Enrollment Request Form - VA 128 (PDF) 09/09/2022
Annuity Contract Change Request Form - VA 109 (PDF) 09/09/2022
Beneficial Owner Life Expectancy Distribution Administration Form (PDF) 09/09/2022
Chronically Ill or Disabled Individual Physician Certification Form (PDF) 09/09/2022
Collateral Assignment Form - VA 106 (PDF) 09/09/2022
Contribution Form - VA 113 (PDF) 09/09/2022
Due Diligence Supplement - VA 123 (PDF) 09/09/2022
Financial Adviser and Broker Dealer Change Request Form - FA CHG (PDF) 09/09/2022
Qualified Birth and Adoption Distribution Repayment Form (PDF) 09/09/2022
Substantially Equal Periodic Payments (SEPP) - VA 126-72TQ (PDF) 09/09/2022
TSA Loan Request Form - VA 105 (PDF) 09/09/2022
Transfer and Allocation Form - VA 118 (PDF) 09/09/2022
Transfer of Assets and Replacement for AK,AL,AZ,CO,CT,HI,IA,KY,LA,MD,ME,MO,MS,NC,NE,NH,NJ,NM,OH,OR,SC,SD,TX,UT,VT,WI,WV - APO-1868-17Z-NA (PDF) 09/09/2022
Transfer of Assets and Replacement for AR - APO-1868-17Z-NA (PDF) 09/09/2022
Transfer of Assets and Replacement for CA - APO-1868-17Z-NA (PDF) 09/09/2022
Transfer of Assets and Replacement for DC, ND - APO-1868-17Z-NA (PDF) 09/09/2022
Transfer of Assets and Replacement for DE - APO-1868-17Z-NA (PDF) 09/09/2022
Transfer of Assets and Replacement for FL - APO-1868-17Z-NA (PDF) 09/09/2022
Transfer of Assets and Replacement for GA - APO-1868-17Z-NA (PDF) 09/09/2022
Transfer of Assets and Replacement for ID, IL, TN - APO-1868-17Z-NA (PDF) 09/09/2022
Transfer of Assets and Replacement for IN - APO-1868-17Z-NA (PDF) 09/09/2022
Transfer of Assets and Replacement for KS - APO-1868-17Z-NA (PDF) 09/09/2022
Transfer of Assets and Replacement for MA - APO-1868-17Z-NA (PDF) 09/09/2022
Transfer of Assets and Replacement for MI - APO-1868-17Z-NA (PDF) 09/09/2022
Transfer of Assets and Replacement for MN - APO-1868-17Z-NA (PDF) 09/09/2022
Transfer of Assets and Replacement for MT - APO-1868-17Z-NA (PDF) 09/09/2022
Transfer of Assets and Replacement for NV - APO-1868-17Z-NA (PDF) 09/09/2022
Transfer of Assets and Replacement for OK - APO-1868-17Z-NA (PDF) 09/09/2022
Transfer of Assets and Replacement for PA - APO-1868-17Z-NA (PDF) 09/09/2022
Transfer of Assets and Replacement for RI - APO-1868-17Z-NA (PDF) 09/09/2022
Transfer of Assets and Replacement for VA - APO-1868-17Z-NA (PDF) 09/09/2022
Transfer of Assets and Replacement for WA - APO-1868-17Z-NA (PDF) 09/09/2022
Transfer of Assets and Replacement for WY - APO-1868-17Z-NA (PDF) 09/09/2022
Transfer of Assets to Nationwide (PDF) 09/09/2022
Advisor Authorization Agreement (PDF) 09/09/2022
Advisor Authorization Agreement (PDF) 09/09/2022
Advisor Fee Instructions (PDF) 09/09/2022
Advisor Fee Instructions (PDF) 09/09/2022
Beneficial Owner Life Expectancy Distribution Administration Form (PDF) 09/09/2022
Beneficial Owner Life Expectancy Distribution Administration Form (PDF) 09/09/2022
Chronically Ill or Disabled Individual Physician Certification Form (PDF) 09/09/2022
Chronically Ill or Disabled Individual Physician Certification Form (PDF) 09/09/2022
Custom Choice Request (PDF) 09/09/2022
Custom Choice Request (PDF) 09/09/2022
NARIA Guaranteed Lifetime Withdrawal Benefit Administration Form (PDF) 09/09/2022
NARIA Guaranteed Lifetime Withdrawal Benefit Administration Form (PDF) 09/09/2022
Qualified Birth and Adoption Distribution Repayment Form (PDF) 09/09/2022
Qualified Birth and Adoption Distribution Repayment Form (PDF) 09/09/2022
Transfer of Assets (PDF) 09/09/2022
Transfer of Assets (PDF) 09/09/2022
5 Year Delayed Income Surrender Request (PDF) 07/01/2022
5 Year Delayed Income Surrender Request (PDF) 07/01/2022
Acord 1035 Exchange Rollover Transfer Form Addendum (PDF) 07/01/2022
Acord 1035 Exchange Rollover Transfer Form Addendum (PDF) 07/01/2022
Acord 1035 Exchange Rollover Transfer Form Addendum (PDF) 07/01/2022
Acord 1035 Exchange Rollover Transfer Form Addendum Beneficial Owner (PDF) 07/01/2022
Additional Beneficiaries Form (PDF) 07/01/2022
Certification of Trust (PDF) 07/01/2022
Certification of Trust (PDF) 07/01/2022
Contract Change Request and Medical Questionnaire (PDF) 07/01/2022
Contract Owner Withdrawal Form (PDF) 07/01/2022
Contract Owner Withdrawal Form (PDF) 07/01/2022
Custodial Owner and Account Change Form (PDF) 07/01/2022
Custodial Owner and Account Change Form (PDF) 07/01/2022
Designation of Restricted Beneficiary for Immediate Annuity (PDF) 07/01/2022
Fund Transfer and Allocation Request (PDF) 07/01/2022
Fund Transfer and Allocation Request (PDF) 07/01/2022
Internal Transfer Disclosure Form (PDF) 07/01/2022
Internal Transfer Disclosure Form (PDF) 07/01/2022
Nationwide Automated Clearing House (ACH) Authorization Form (PDF) 07/01/2022
Nationwide Automated Clearing House (ACH) Authorization Form (PDF) 07/01/2022
Non-Lifetime Withdrawal Form (PDF) 07/01/2022
Non-Lifetime Withdrawal Form (PDF) 07/01/2022
Payout Beneficiary Claim Form (PDF) 07/01/2022
Producer Information Form (PDF) 07/01/2022
Release of Collateral Assignment (PDF) 07/01/2022
Release of Collateral Assignment (PDF) 07/01/2022
Restriction of Beneficiary Options (PDF) 07/01/2022
SPIA Only - Liquidity Withdrawal Request (PDF) 07/01/2022
SPIA Only - Payee Administration Form (PDF) 07/01/2022
Nationwide Insurance Only Producer Non-Solicitation Form (PDF) 04/29/2022
Annuity Beneficiary Claim Form (PDF) 01/14/2022
Annuity Beneficiary Claim Form (PDF) 01/14/2022
Annuity Beneficiary Claim Form (PDF) 01/14/2022
Payout Beneficiary Claim Form (PDF) 01/14/2022
Beneficiary Change Request (PDF) 11/19/2021
Beneficiary Change Request (PDF) 11/19/2021
Immediate Annuity Owner Change Request (PDF) 11/19/2021
Required Minimum Distribution (RMD) Request Form (PDF) 11/19/2021
Beneficiary Change Request (PDF) 11/01/2021
Required Minimum Distribution (RMD) Request Form (PDF) 11/01/2021
Restriction of Beneficiary Options (PDF) 11/01/2021
Beneficiary Change Request (PDF) 11/01/2021
Contract Change Request and Medical Questionnaire (PDF) 11/01/2021
Required Minimum Distribution (RMD) Request Form (PDF) 11/01/2021
Restriction of Beneficiary Options (PDF) 11/01/2021
Restriction of Beneficiary Options (PDF) 11/01/2021
Designation of Restricted Beneficiary for Immediate Annuity (PDF) 06/11/2021
Additional Beneficiaries Form (PDF) 09/07/2018
Producer Information Form (PDF) 09/07/2018
SPIA Only - Liquidity Withdrawal Request (PDF) 09/07/2018
SPIA Only - Payee Administration Form (PDF) 09/07/2018

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