VAF-0213AO.10 01/2015

Scheduled Withdrawal FormNot for one-time withdrawals or transfers

1b. Reason for SubmissionInitiate new requestReplace or change existing scheduled withdrawal

Please complete section 2 or 3 depending upon the type of scheduled withdrawal you wish to initiate or change. For all types of withdrawal requests, you must complete sections 4, 5, and 6, and sign in section 9 after reading the disclosures.

Please check only

one box.STOP

Important Information:• 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

1. General Information Please print.

1a. Owner InformationDo not fill out Section 1a if this withdrawal request is submitted along with a new contract application. For existing contracts Section 1a must be completed. STOP

( )

Owner’s First/Last Name:

Existing Contract Number: (Required)

(Important) Social Security Number: Telephone

Number:

Owner’s Address:

City/State/ZIP:

Mail to: Nationwide Life Insurance Company and Nationwide Life and Annuity Insurance Company P.O. Box 182021, Columbus, Ohio 43218-2021, 1-800-848-6331, Fax to: 1-888-634-4472, nationwide.com Page 1 of 4

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VAF-0213AO.10 01/2015

2. Systematic Withdrawal Not for contracts with Nationwide Income Architect Guaranteed Withdrawal or contracts with Lifetime Income. Lifetime Income withdrawal requests should be submitted on the Lifetime Income Withdrawal Administrative form.

Withdrawal Options

1 Calculated by Nationwide

Specific Amount: $

Interest Only Amount Select only one option. Available only for fixed annuity products that allow this option.

Penalty Free/Age Based Amount 1

Scheduled Withdrawal Form Page 2 of 4

3. Capital Preservation Plus Lifetime Income (CPPLI) 6% Immediate Withdrawal Benefit

Capital Preservation Plus Lifetime Income (CPPLI) 6% Immediate Withdrawal Benefit 1

1 Calculated by NationwidePlease carefully review disclosure section 7b before choosing this option.

For Lifetime Income, please complete the Capital Preservation Plus Administrative form.

!

Net Amount - total after taxes and chargesGross Amount - total before taxes and charges (Default)

All accrued interest from Contract inception to date

2a.

2b.

2c.

2.

Annually Semi-Annually Quarterly MonthlyCalculate amount based on frequency period requested 11.

(Dollars) (Cents) , .

A new form needs to be completed annually, and will be sent automatically 45 days prior to your contract anniversary.

4. Program Information Must be completed for all requests. 4a. Withdrawal Frequency Please select one option.

4b. Start Date

/ /MM YYYYDD

Annually Semi-Annually Quarterly Monthly

If this section is blank, we will default to monthly withdrawals. !If this section is blank, we will default to current day.!

VAF-0213AO.10 01/2015

Scheduled Withdrawal Form Page 3 of 4

Federal Withholding %

For state withholding, please list your state of residence1:

State Withholding %

Do not withhold taxes (if you wish to have taxes withheld, complete below)If this section is blank, we will default to withholding taxes.!1If 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.

5. Tax Withholding Required for all requests.

6. Method of Payment Required for all requests. Please check only one.

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 this option 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. The deposit to your checking or savings account will normally occur 2-3 business days after the date of the scheduled withdrawal from your annuity contract. If you change your bank/financial institution, please notify Nationwide immediately. 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

Third Party For Benefit of (FBO) (Please fill out the following fields)

Check payable to/Name:

Address:

City, State, ZIP:

VAF-0213AO.10 01/2015

Scheduled Withdrawal Form Page 4 of 4

7. Disclosure and Certification 7a. General Information •BysigningIcertifythattheSocialSecuritynumberlistedonthisformismycorrecttaxpayeridentificationnumber•Thisrequestwillremainineffectuntilthecontractvalueisdepletedoruntilcancelledinwriting,exceptforage-basedwithdrawals•Yourcheckwillnormallybesentthedayafterthewithdrawaldate.Ittypicallytakes4-5businessdaystoreceiveyourcheckand2-3business days for direct deposit. Please take this into consideration when selecting your withdrawal date •IfdirectdepositisselectedavoidedcheckorletterfromthefinancialinstitutionthatshowsyourABA(i.e.Transitroutingnumber)andaccount numbers will be required •BychoosingthePenaltyFree/AgeBasedoption,Nationwidewillchoosethegreaterofthetwovaluesifapplicable•ContingentDeferredSalesChargesmaybedeductedfromthesedistributionsasoutlinedintheContract•ForcontractswiththeExtraValueOption,aforfeituremayoccurifthepenaltyfreeamountisexceeded•Youareliableforallfederalandstateincometaxwithholdingsonthetaxableportionofthewithdrawal.Youmayalsobesubjecttotaxpenalties under the estimated tax payment rules if your payments of estimated tax withholding, if any, are not sufficient•A10%federaltaxpenaltymaybeassessedtowithdrawalsontheannuitycontractifthecontractownerisunder59 1/2•Withholdingwithrespectto403(b)andqualifiedplansis20%,ifthedistributionisaneligiblerolloverdistribution(ERD).Ifthedistribution is not an ERD, then withholding is elective. If no election is stated, the default withholding will be 10% •Defaultwithholdingis10%forIRAandNon-Qualifiedand20%for403(B)andQualifiedPlancontracttypes•Pleaseconsultwithyourtaxadvisoronthesematters•Withdrawalsinexcessoftheguaranteedwithdrawalamount,called“excesswithdrawals”,mayresultinapermanentreductioninfutureguaranteed 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

•Ifnotindicatedotherwiseonthisform,withdrawalswillbemadeproportionallyfromvariablefundsandguaranteedtermoptionaccounts and could result in a market value adjustment.• Choosing the 6% Immediate Withdrawal Benefit eliminates the Lifetime Income Option of CPPLI. For more information on the Immediate Withdrawal Benefit and the effects on the CPPLI Rider, please consult your rider and your prospectus.

7b. CPPLI 6% Immediate Withdrawal Benefit

8. 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), and2) 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, and3) I am a U.S. citizen or other U.S. person, and4) 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.

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

9. Signature (Required)

Contract Owner’s Name: SSN: - -

(Required)

Contract Owner’s Signature: X Date:

Joint Contract Owner’s Name: (If applicable)

Joint Contract Owner’s Signature: X Date: