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  • We offer tax deferring capacity for clients who've maxed out their plans or received a large sum of money.

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  • Service Forms

Service Forms

File Name
Updated
5 Year Delayed Income Surrender Request 07/01/2022 NARIA
5 Year Delayed Income Surrender Request 07/01/2022 NARIAFBSEL
Account Change Request 07/01/2022 NARIAFBSEL
Acord 1035 Exchange Rollover Transfer Form Addendum 07/01/2022 NARIA
Acord 1035 Exchange Rollover Transfer Form Addendum 07/01/2022 FBSEL
Acord 1035 Exchange Rollover Transfer Form Addendum 07/01/2022 NARIAFBSEL
Acord 1035 Exchange Rollover Transfer Form Addendum Beneficial Owner 07/01/2022 NARIAFBSEL
Additional Beneficiaries Form 07/01/2022 NARIAFBSEL
Certification of Trust 07/01/2022 NARIA
Certification of Trust 07/01/2022 NARIAFBSEL
Contract Owner Withdrawal Form 07/01/2022 NARIA
Contract Owner Withdrawal Form 07/01/2022 NARIAFBSEL
Custodial Owner and Account Change Form 07/01/2022 NARIA
Custodial Owner and Account Change Form 07/01/2022 NARIAFBSEL
Fund Transfer and Allocation Request 07/01/2022 NARIA
Fund Transfer and Allocation Request 07/01/2022 NARIAFBSEL
Internal Transfer Disclosure Form 07/01/2022 NARIAFBSEL
Internal Transfer Disclosure Form 07/01/2022 NARIA
Lifetime Withdrawal Form 07/01/2022 NARIAFBSEL
Non-Lifetime Withdrawal Form 07/01/2022 NARIAFBSEL
Non-Lifetime Withdrawal Form 07/01/2022 NARIA
Release of Collateral Assignment 07/01/2022 NARIA
Release of Collateral Assignment 07/01/2022 NARIAFBSEL
Restriction of Beneficiary Options 07/01/2022 FBSEL
Investment Instructions - Monument Advisor Select 04/29/2022 JMON3
Investment Instructions -Monument Advisor 04/29/2022 JMON3
Custom Choice Request 04/29/2022 NARIA
Nationwide Insurance Only Producer Non-Solicitation Form 04/29/2022 NARIA
Transfer of Assets and Replacement for ID, IL, TN - APO-1868-17Y-NA 02/25/2022 JMON3
Annuity Beneficiary Claim Form 01/14/2022 JMON3
Annuity Beneficiary Claim Form 01/14/2022 NARIA
Annuity Beneficiary Claim Form 01/14/2022 NARIAFBSEL
Payout Beneficiary Claim Form 01/14/2022 FBSEL
Payout Beneficiary Claim Form 01/14/2022 NARIAFBSEL
Beneficiary Change Request 11/19/2021 NARIA
Beneficiary Change Request 11/19/2021 FBSEL
Immediate Annuity Owner Change Request 11/19/2021 FBSEL
Required Minimum Distribution (RMD) Request Form 11/19/2021 NARIA
Advisor Authorization Agreement 11/01/2021 JMON3
Beneficial Owner Life Expectancy Distribution Administration Form 11/01/2021 JMON3
Beneficiary Change Request 11/01/2021 JMON3
Required Minimum Distribution (RMD) Request Form 11/01/2021 JMON3
Restriction of Beneficiary Options 11/01/2021 JMON3
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-1868-17Y-NA 11/01/2021 JMON3
Transfer of Assets and Replacement for AR - APO-1868-17Y-NA 11/01/2021 JMON3
Transfer of Assets and Replacement for CA - APO-1868-17Y-NA 11/01/2021 JMON3
Transfer of Assets and Replacement for DE - APO-1868-17Y-NA 11/01/2021 JMON3
Transfer of Assets and Replacement for FL - APO-1868-17Y-NA 11/01/2021 JMON3
Transfer of Assets and Replacement for GA - APO-1868-17Y-NA 11/01/2021 JMON3
Transfer of Assets and Replacement for IN - APO-1868-17Y-NA 11/01/2021 JMON3
Transfer of Assets and Replacement for KS - APO-1868-17Y-NA 11/01/2021 JMON3
Transfer of Assets and Replacement for MA - APO-1868-17Y-NA 11/01/2021 JMON3
Transfer of Assets and Replacement for MI - APO-1868-17Y-NA 11/01/2021 JMON3
Transfer of Assets and Replacement for MN - APO-1868-17Y-NA 11/01/2021 JMON3
Transfer of Assets and Replacement for MT - APO-1868-17Y-NA 11/01/2021 JMON3
Transfer of Assets and Replacement for NV - APO-1868-17Y-NA 11/01/2021 JMON3
Transfer of Assets and Replacement for OK - APO-1868-17Y-NA 11/01/2021 JMON3
Transfer of Assets and Replacement for PA - APO-1868-17Y-NA 11/01/2021 JMON3
Transfer of Assets and Replacement for RI - APO-1868-17Y-NA 11/01/2021 JMON3
Transfer of Assets and Replacement for VA - APO-1868-17Y-NA 11/01/2021 JMON3
Transfer of Assets and Replacement for WA - APO-1868-17Y-NA 11/01/2021 JMON3
Transfer of Assets and Replacement for WY - APO-1868-17Y-NA 11/01/2021 JMON3
Account Change Request 11/01/2021 NARIA
Advisor Authorization Agreement 11/01/2021 NARIA
Annuity Beneficiary Claim Form 11/01/2021 NARIAFBSEL
Beneficial Owner Life Expectancy Distribution Administration Form 11/01/2021 NARIA
Beneficiary Change Request 11/01/2021 NARIAFBSEL
Deferred Annuitization Election Form 11/01/2021 NARIA
Lifetime Withdrawal Form 11/01/2021 NARIA
Required Minimum Distribution (RMD) Request Form 11/01/2021 NARIAFBSEL
Restriction of Beneficiary Options 11/01/2021 NARIAFBSEL
Restriction of Beneficiary Options 11/01/2021 NARIA
Transfer of Assets 11/01/2021 NARIA
Transfer of Assets to Nationwide 08/08/2021 JMON3
Designation of Restricted Beneficiary for Immediate Annuity 06/11/2021 FBSEL
Systematic Partial Withdrawal Form (Non-Qualified) – VA 102 SYSNQ 05/28/2021 JMON3
Annuity Contract Change Request Form - VA 109 09/11/2020 JMON3
Advisor Fee Instructions - VA151 07/24/2020 JMON3
Contribution Form - VA 113 07/24/2020 JMON3
Systematic Partial Withdrawal (Qualified) - VA 102 SYSQ 07/24/2020 JMON3
Agent Enrollment Request Form - VA 128 06/26/2020 JMON3
Annuitization - Settlement Request Qualified or Non-Qualified Form - VA 120 06/26/2020 JMON3
Collateral Assignment Form VA 106 06/26/2020 JMON3
Due Diligence Supplement - VA 123 06/26/2020 JMON3
Financial Adviser and Broker Dealer Change Request Form - FA CHG 06/26/2020 JMON3
Interest Sweep Request Form - VA 117 06/26/2020 JMON3
ORP Restriction Form - VA ORP 06/26/2020 JMON3
Periodic Payment Enrollment Form (Non-Qualified) - VA126 - 72Q 06/26/2020 JMON3
Periodic Payment Enrollment Form (Qualified) - VA126 - 72T 06/26/2020 JMON3
TSA Hardship Withdrawal Request - VA 107 06/26/2020 JMON3
TSA Loan Request Form - VA 105 06/26/2020 JMON3
Third Party Payee Request Form - VA 112 06/26/2020 JMON3
Transfer and Allocation Form - VA 118 06/26/2020 JMON3
Advisor Fee Instructions - NW 09/01/2019 NARIA
Additional Beneficiaries Form 09/07/2018 NARIA
Producer Information Form 09/07/2018 NARIA
SPIA Only - Liquidity Withdrawal Request 09/07/2018 FBSEL
SPIA Only - Payee Administration Form 09/07/2018 FBSEL
EFT Request Form - VA 110 04/27/2018 JMON3
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• Not a deposit • Not FDIC or NCUSIF insured • Not guaranteed by the institution • Not insured by any federal government agency • May lose value

This material is not a recommendation to buy or sell a financial product or to adopt an investment strategy. Investors should discuss their specific situation with their financial professional.

Annuity products are issued by Nationwide Life Insurance Company or Nationwide Life and Annuity Insurance Company, Columbus, Ohio. The general distributor for variable products is Nationwide Investment Services Corporation, member FINRA, Columbus, Ohio. Nationwide Funds are distributed by Nationwide Fund Distributors, LLC, member FINRA, Columbus, OH. Nationwide Life Insurance Company, Nationwide Life and Annuity Company, Nationwide Investment Services Corporation and Nationwide Fund Distributors are separate but affiliated companies.

Monument Advisor and Monument Advisor Select are issued in all states, except NY, by Jefferson National Life Insurance Company, Dallas, TX. In New York, Monument Advisor and Monument Advisor Select are issued by Jefferson National Life Insurance Company of New York, New York, NY. The general distributor is Jefferson National Securities Corporation, member FINRA, Louisville KY.

Nationwide, the Nationwide N and Eagle, Nationwide is on your side, Nationwide Funds Group and Nationwide Retirement Institute are service marks of Nationwide Mutual Insurance Company.

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ASW-0200AO (02/22)

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