Contract - Nationwide Life Insurance - 8/26/2021 APPLICATION FOR
GROUP FLEXIBLE PURCHASE PAYMENT DEFERRED
Nationwide' FIXED INDEXED ANNUITY CONTRACT(Non-Participating)
underwritten by
Nationwide Life Insurance Company
One Nationwide Plaza
Columbus,Ohio 43215
1-877-677-3678
Nationwide Indexed Principal Protection5m
Please indicate for which product this application applies(one must be selected):
❑ 12-month Book Value Payment ® 5-year Book Value Payment
APPLICANT
City of Round Rock,Texas _ _ (the"Applicant"), applies to be the Contract Owner
of a Group Flexible Purchase Payment Deferred Fixed Indexed Annuity Contract(the"Contract")underwritten by Nationwide Life
Insurance Company("Nationwide").
The Group Flexible Purchase Payment Deferred Fixed Indexed Annuity Contract applied for will become effective on the"Effective
Date of Contract" if the initial Purchase Payment and this application are accepted by Nationwide. In the event the initial Purchase
Payment or this application are not accepted,Nationwide's liability will be limited to a return of the initial Purchase Payment,and any
subsequent Purchase Payments remitted.
The applicant's plan qualifies under-
® Section 457(b) ❑ Section 401(k) ❑ Section 401(a)
_— — -- —
PURCHASE PAYMENT
Applicant agrees to permit Participants in its Plan to allocate Purchase Payments to the Contract as of the"Effective Date of Contract".
SIGNATURES
A market value adjustment may occur on the effective date of termination. / ,
Signed on behalf of CL RRockthisZLV day
of ec
❑ Yes ®No Do you have existing annuity contracts?
❑ Yes ®No Will the applied for Contract replace any existing life insurance or annuity contracts?
Applicant's signature below indicates that the applicant acknowledges and understands that he/she is applying
for an index-based product, and that the applicant acknowledges and understands that while the values of the
policy may the affected by an external index, the policy does not directly participate in any stock or equity
investments
1 ) /
(Authorized Si a of A licant) Date
.JwMAA4%w1
(Title) Li
NRAA-0153TX I (Texas)(62020)
SIGNATURES
❑ Yes No Do you have any reason to believe the Contract applied for is to replace existing annuities?
g— 9^ 202
(Authorized ationwide Agent/Representative Signature) Date
Sa,rt+.— 1 u, ( (
(Authorized Nationwide Agent/Representative)—Please Print
(Title)
7q ��
�v i 5• r P2
NRAA-0153TX 2 (Texas)(6/2020)
.......... ..... .......
CERTIFICATE OP INTERESTED PARTIES FORM 1295
1 of 1
Complete Nos.1-4 and 6 if there are interested parties. OFFICE USE ONLY
Complete Nos.1,2,3,5,and 6 if there are no interested parties. CERTIFICATION OF FILING
1 Name of business entity filing form,and the city,state and country of the business entity's place Certificate Number:
of business. 2021-787723
Nationwide
Columbus,,OH United States Date Filed:
2 Name of governmental entity or state agency that is a party to the contract for which the form is 08/06/2021
being filed.
City of Round Rock,TX Date Acknowledged:
3 Provide the identification number used by the governmental entity or state agency to track or identify the contract,and provide a
description of the services,goods,or other property to be provided under the contract.
0037434001
Deferred Compensation Provider
Nature of interest
4
Name of interested Party City,State,Country(place of business) (check applicable)
Controlling I Intermediary
Studebaker,Michael Columbus,OH United States X
5 Check only if there is NO Interested Party.
6 UNSWORN DECLARA,'nO//��N �, _/
fv9y name is
/�C.Ytae,/ J-1 [�7-L'ba ze,� and my date of birth is
My address is �V f/V • / U tfz y�W fi t. �U , � ._. y�o�l 7 0
(street) (city) (state) (zip code) (country)
I declare under penalty of perjury that the foregoing is true and correct
Executed in91
t�� r �� County, State of �f on the C5 day of/77a K 20-..
( onth) (year)
Signature of auth tzed agent of contract�W.,rh�es entity
(Declarant)
Farms provided by Texas Ethics Commission vrww.ethics.state.tx.us Version V1.1.ceffdg8a
CERTIFICATE OF INTERESTED PARTIES
FORM 1295
lofl
Complete Nos.1-4 and 6 if there are interested parties. OFFICE USE ONLY
Complete Nos.1,2,3,5,and 6 if there are no interested parties. CERTIFICATION OF FILING
1 Name of business entity filing form,and the city,state and country of the business entity's place Certificate Number:
of business. 2021-787723
Nationwide
Columbus, , OH United States Date Filed:
2 Name of governmental entity or state agency that is a party to the contract for which the form is 08/06/2021
being filed.
City of Round Rock, TX Date Acknowledged:
08/09/2021
g Provide the identification number used by the governmental entity or state agency to track or identify the contract,and provide a
description of the services,goods,or other property to be provided under the contract.
0037434001
Deferred Compensation Provider
Nature of interest
4
Name of Interested Party City,State,Country(place of business) (check applicable)
Controlling Intermediary
Studebaker, Michael Columbus, OH United States X
5 Check only if there is NO Interested Party. ❑
6 UNSWORN DECLARATION
My name is and my date of birth is
My address is
(street) (city) (state) (zip code) (country)
I declare under penalty of perjury that the foregoing is true and correct.
Executed in County, State of on the day of ,20
(month) (year)
Signature of authorized agent of contracting business entity
(Declarant)
Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version V1.1.ceffd98a