Page 1 of 4APO-5310-K (8/2015)

1. Current Owner’s Information (please print - all fields required)

2. New Owner’s Information (please print - all fields required)

Owner Change RequestNationwide Life Insurance Company

Nationwide Life and Annuity Insurance CompanyPO Box 182021, Columbus, OH 43218-2021

Phone: 800-848-6331 • Fax: 888-634-4472 • nationwide.com

Current Owner’s Information:

Name: Contract Number:

SSN: Gender: c Male c Female Date of Birth:

Street Address:

City: State: ZIP:

Phone: Email:

Resident State ( c same as address): Relationship to Annuitant:

Joint Owner’s Information (if applicable):

Name: Date of Birth:

Fc For Current Owner address changes, please check this box, proceed to section 8, sign, date, and return this form to us for processing.

• Ownership changes may result in a taxable event. Please contact your tax or legal advisor before proceeding

• Ownership changes are not permitted on existing contracts with The Nationwide Lifetime Income Rider® or Guaranteed Lifetime Withdrawal Benefit

• Where permitted under law, if the contract owner is changed or the contract is assigned on a Nationwide Destination℠ B (2.0), Nationwide Destination℠ L (2.0), Nationwide Destination℠ EV (2.0), Nationwide Destination℠ Navigator (2.0), Nationwide Destination℠ All American Gold (2.0), Nationwide Destination℠ Architect (2.0), Nationwide Destination Freedom+℠, Waddell & Reed Advisors Select Preferred Annuity℠ (2.0) contract, the Standard Death Benefit or any enhanced death benefit will terminate and the death benefit will be the Contract Value, and, if elected, the Nationwide Lifetime Income Rider® rider on your contract will terminate, except for the following circumstances: 1) the new contract owner or Assignee assumes full ownership of the contract and is essentially the same person (e.g. an individual ownership changed to the personal revocable trust, a change to the contract owner’s spouse during the contract owner’s lifetime, a change to a court-appointed guardian representing the contract owner during the contract owner’s lifetime, etc); 2) ownership of an IRA or Roth IRA is being changed from one custodian to another, from the contract owner to a custodian, or from a custodian to the contract owner; or 3) the assignment is for the purpose of effectuating a 1035 exchange of the contract (i.e. the benefits may continue during the temporary assignment period and not terminate until the contract is actually surrendered)

New Owner’s Information:

Name: Contract Number:

SSN: Gender: c Male c Female Date of Birth:

Street Address:

City: State: ZIP:

Phone: Email:

Resident State ( c same as address): Relationship to Annuitant:

Relationship to Former Owner:

Reason for Ownership Change:

New Joint Owner’s Information (if applicable):

Name:

SSN: Gender: c Male c Female Date of Birth:

Phone: Email:

Relationship to Annuitant:

Page 2 of 4APO-5310-K (8/2015)

4. Required Selection

A non-natural owner is defined as a legal entity other than a living person. A natural person is defined as a living person. A contract owned by an entity other than a living person has a non-natural owner.

The contract owner is a (please select only one):

TRUSTFc Grantor / Living / Revocable TrustFc Charitable Remainder Trust / Charitable Lead TrustFc Please Name Type:

ENTITYFc CorporationFc PartnershipFc Sole Proprietorship (Company or Business)Fc Limited Liability Company (LLC) c Check this box if electing to be treated as a Corporation

OTHER (Estate / Structured Settlement / Family Limited Partnership / Qualified Plan /Foundation / Etc.)Fc Please Name Type:

If a selection is not made, Nationwide will default to “Not acting as an agent” which means the contract will lose the tax deferred status for tax purposes.

Select only one. (Please review these choices with your legal counsel.)Fc The entity selected above IS acting as an agent of the natural person.Fc The entity selected above IS NOT acting as an agent of a natural person. (Contract will lose tax deferral standing and earnings may be reported annually on Form 1099-MISC.)

5. New Beneficiary Designations

3. Owner Type

Important! Previous beneficiary(ies) will remain in effect unless this section is updated with new beneficiary designation.

Allocation to all Primary Beneficiaries must equal 100%. Use only whole percentages, fractions may delay processing.

Primary Beneficiary(ies) (allocations must total 100%): c Pay all Primary Beneficiaries equally

1. Full Legal Name:

Relationship to Annuitant: Allocation (whole % only): %

SSN: Gender: c Male c Female Date of Birth:

Fc Same address as Owner

Street Address:

City: State: ZIP:

Phone: Email:

2. Full Legal Name:

Relationship to Annuitant: Allocation (whole % only): %

SSN: Gender: c Male c Female Date of Birth:

Fc Same address as Owner

Street Address:

City: State: ZIP:

Phone: Email:

3. Full Legal Name:

Relationship to Annuitant: Allocation (whole % only): %

SSN: Gender: c Male c Female Date of Birth:

Fc Same address as Owner

Street Address:

City: State: ZIP:

Phone: Email:

Page 3 of 4APO-5310-K (8/2015)

5. New Beneficiary Designations (continued)

6. Disclosure

7. Important Information

Important! Previous beneficiary(ies) will remain in effect unless this section is updated with new beneficiary designation.

Allocation to all Contingent Beneficiaries must equal 100%. Use only whole percentages, fractions may delay processing.

Contingent Beneficiary(ies) (allocations must total 100%): c Pay all Contingent Beneficiaries equally

1. Full Legal Name:

Relationship to Annuitant: Allocation (whole % only): %

SSN: Gender: c Male c Female Date of Birth:

Fc Same address as Owner

Street Address:

City: State: ZIP:

Phone: Email:

2. Full Legal Name:

Relationship to Annuitant: Allocation (whole % only): %

SSN: Gender: c Male c Female Date of Birth:

Fc Same address as Owner

Street Address:

City: State: ZIP:

Phone: Email:

3. Full Legal Name:

Relationship to Annuitant: Allocation (whole % only): %

SSN: Gender: c Male c Female Date of Birth:

Fc Same address as Owner

Street Address:

City: State: ZIP:

Phone: Email:

Pursuant to its reliance on the SEC Rule 12h-7 under the Exchange Act of 1934, Nationwide Life Insurance Company (“Company”) is required to take steps reasonably designed to ensure that a trading market for certain variable annuities does not develop. To prevent the development of a trading market, the Company reserves the right to not approve a change of ownership or assignment, where permitted by law.

• I understand the purpose and intent of the contract referenced above is to offer benefits to individuals and their beneficiaries. I hereby acknowledge that I do not represent a corporate entity or institutional investor. I do not intend to assign any benefits under this contract to a corporate entity or institutional investor. Where permitted by law, Nationwide may reject assignments and/or contract owner changes that alter the nature of the risk Nationwide intended to accept when the contract was issued

• The contract owner’s address of record will be changed to reflect that of the New Custodial Owner

• For the transfer of specific contracts or all contracts within a firm, the signature of a principal of the firm is required

• For the transfer of specific contracts or all contracts from one firm to another, the signature of a principal from both firms is required. The relinquishing firm must also have a Blanket Transfer Amendment in their selling agreement with Nationwide

• If the contract has an existing Scheduled Withdrawal, it will be terminated. If you wish to set up a new Scheduled Withdrawal, you must include a completed Scheduled Withdrawal form with this request

• For Custodial contracts, the contract will be updated to reflect the New Custodian as sole beneficiary

Page 4 of 4APO-5310-K (8/2015)

8. Signatures (required)

Nationwide, the Nationwide N and Eagle and Nationwide is on your side are service marks of Nationwide Mutual Insurance Company. ©2015 Nationwide

Current Owner:Full Name (please print):

Signature: Date:

Current Joint Owner (if applicable):

Full Name (please print):

Signature: Date:

New Owner:Full Name (please print):

Signature: Date:

New Joint Owner (if applicable):

Full Name (please print):

Signature: Date: