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Nationwide' <br />APPLICANT --- <br />Indian River County BOCC <br />APPLICATION FOR <br />GROUP FLEXIBLE PURCHASE PAYMENT DEFERRED FIXED ANNUITY CONTRACT <br />underwritten by <br />Nationwide Life Insurance Company <br />One Nationwide Phi <br />Columbus, Ohio 43215 <br />(the "Applicant"), applies to be the Contract Owner of a <br />Group Flexible Purchase Payment Deferred Fixed Annuity Contract (the "Contract") underwritten by Nationwide Life Insurance Company <br />("Nationwide"). <br />The Group Flexible Purchase Payment Deferred Fixed Annuity Contract applied for will become effective on the "Effective Date of Contract" if the <br />initial Purchase Payment and this application are accepted by Nationwide. In the event the initial Purchase Payment or this application are not <br />accepted, Nationwide's liability will be limited to a return of the initial Purchase Payment, and any subsequent Purchase Payments remitted. <br />PURCHASE PAYMENT <br />Applicant agrees to permit Participants in its Plan to allocate Purchase Payments to the Contract as of the "Effective Date of Contract". <br />TRANSFER AND EXCHANGE LIMITATION ELECTION --� <br />Elect One: <br />❑ Contract Level At'sreeate Exchange Limitation (the limitation on Outgoing Exchanges from the Fixed Account is determined based on total <br />assets held in the Contract's Fixed Account's value under the Contract as of the last Business Day preceding the current calendar year). <br />M Participant Level Ezchanee Limitation (the limitation on Outgoing Exchanges from the Contract is applied to each Participant Account under <br />the Contract The Contract Owner, or its designated Record Keeper is responsible for applying this limitation). <br />STATE INSURANCE FRAUD WARNINGS <br />FOR FL RESIDENTS ONLY: Any person who knowingly and with intent to injure, dehwrd, or deceive any insurer files a statement of claim or an application <br />containing any false, incomplete, or misleading information is guilty of a felony of the third de&W. <br />ONAL STATE NOTICES <br />NOTICE TO FL RESIDENTS ONLY: Annuity payments, death benefits, surrender values, and other Contract Values are subject to a market value adjustment, and <br />are not guaranteed as to fired dollar amount, unless otherwise specified. <br />SIGNATURES <br />Si on behalf Indian River County BOCC 457(b) Deferred Compensation Plan _�f �y of <br />��2 _this <br />Yes ❑ No Do you have life insurance or annuity contracts? <br />Yes No will the appl �ontract replace any existing life insurance or annuity contracts? <br />[(iSadzectSignfu of Apieant) <br />i r <br />Yes ❑ No Do you have any reason to believe the Contract applied for is to replace existing annuities or insurance? <br />[(Authorized Nationwide Agent(Representative Signature)] <br />(Authorized Nationwide Agent(Representative — Please Print) <br />[(Title)] <br />Florida License Identification #: (Florida Agents only) <br />Date <br />NRA-0I05FL.I (Florida) (1112007) <br />136 <br />