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Exhibit 5
THE BEST OF AMERICA(R)
[THE BEST OF AMERICA LOGO] AMERICA'S INCOME ANNUITY(SM)
APPLICATION
$35,000 MINIMUM PURCHASE PAYMENT
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PLAN TYPE This contract is established as a A PLAN TYPE MUST BE SELECTED
[ ] 403(b) TRANSFER DISCLOSURE FORM REQUIRED. [ ] NON-QUALIFIED [ ] IRA
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DISTRIBUTION CHANNEL:
[ ] ID [ ] Agency [ ] NRS [ ] Pensions [ ] FI [ ] Wirehouse [ ] Other_______
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CONTRACT OWNER [ ]JOINT OWNER SPOUSE ONLY UNLESS PROHIBITED BY
Last Name or Trust Name Last Name
First Name or Trust Name (CONTINUED) MI First Name MI
Address Address
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Telephone No. ( ) [ ]H [ ]W
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Sex [ ]M [ ]F Birthdate / / Sex [ ]M [ ]F Birthdate / /
MM DD YYYY MM DD YYYY
Maximum issue age through age 85 Maximum issue age through age 85
Soc. Sec. No. or Tax ID Soc. Sec. No. or Tax ID
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ANNUITANT COMPLETE ONLY IF DIFFERENT FROM [ ] JOINT ANNUITANT COMPLETE ONLY
CONTRACT OWNER IF INCOME OPTION ALLOWS PAYMENTS
TO A SURVIVOR. SPOUSE ONLY FOR
TSA OR XXX.
Last Name Last Name
First Name MI First Name MI
Address Address
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Telephone No. ( ) [ ]H [ ]W
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Sex [ ]M [ ]F Birthdate / / Sex [ ]M [ ]F Birthdate / /
MM DD YYYY MM DD YYYY
Maximum issue age through age 85 Maximum issue age through age 85
Soc. Sec. No. or Tax ID Soc. Sec. No. or Tax ID
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BENEFICIARY WHOLE PERCENTAGES ONLY, ALL PRIMARY BENEFICIARIES MUST TOTAL 100%;
ALL CONTINGENT BENEFICIARIES MUST TOTAL 100%.
Relationship
Primary Contingent Print Full Name (Last, First, MI) Allocation to Annuitant Soc. Sec. No.
[ ] __________________________________ ___________% ___________ ____________________
[ ] [ ] __________________________________ ___________% ___________ ____________________
[ ] [ ] __________________________________ ___________% ___________ ____________________
[ ] [ ] __________________________________ ___________% ___________ ____________________
APO-4365 Product of Nationwide Life Insurance Co. AO (3/1999)
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REMARKS
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INCOME START DATE (NO LATER THAN 60 DAYS AFTER DATE OF ISSUE) ______________
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FREQUENCY OF PAYMENTS [ ]Monthly [ ]Quarterly [ ]Semi-Annually [ ]Annually
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[ ] Electronic Funds Transfer (If Electronic Funds Transfer is not selected, a
check will be issued and mailed to you.)
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Bank Name and Address Bank Telephone Number ( )
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Type of Account (PLEASE ATTACH VOIDED
CHECK OR DEPOSIT SLIP)
[ ] Checking [ ] Savings
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Bank Routing No. Bank Account No.
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INCOME OPTIONS CANNOT BE CHANGED ONCE ELECTED
(only one option may be selected)
[ ] SINGLE LIFE WITH TERM CERTAIN ____YEARS*
[ ] SINGLE LIFE CASH REFUND*
[ ] SINGLE LIFE*
[ ] JOINT AND ____% LAST SURVIVOR**
[ ] JOINT AND ____% LAST SURVIVOR WITH TERM CERTAIN ____YEARS**
[ ] JOINT AND ____% SURVIVOR WITH CASH REFUND**
[ ] JOINT AND ____% SURVIVOR**
[ ] TERM CERTAIN ____ YEARS
[ ] TERM CERTAIN WITH ENHANCED DEATH BENEFIT ____ YEARS
*Birth Certificate of Annuitant Required **Birth Certificate of Both Annuitant
and Joint Annuitant Required
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PURCHASE PAYMENT [ ] ROLLOVER [ ] PAYMENT ENCLOSED [ ] TRANSFER/1035
(requires transfer form)
Single Purchase Payment $__________ submitted (minimum $35,000). A copy of this
application properly signed by the producer will constitute receipt for such
amount. If this application is declined by the Company, there will be no
liability on the part of the Company, and any payments submitted with this
application will be refunded.
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PURCHASE PAYMENT ALLOCATION WHOLE PERCENTAGES ONLY, MUST TOTAL 100%. A
CONTRACT CANNOT BE ISSUED UNLESS THIS SECTION
IS COMPLETE.
ALLOCATION OF PURCHASE PAYMENT TO FIXED ANNUITY PAYMENTS: ________%
ALLOCATION OF PURCHASE PAYMENT TO VARIABLE ANNUITY PAYMENTS: ________%
ASSUMED INVESTMENT RETURN [ ] 3.5% [ ] 5.0% [ ] 6.0%
ANNUAL BENEFIT LEVELING FOR VARIABLE ANNUITY PAYMENTS* [ ] YES [ ] NO
*If this option is elected, Annual Frequency of Payments cannot be chosen.
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ALLOCATION OF INVESTMENT OPTIONS TO PROVIDE VARIABLE
ANNUITY PAYMENTS (WHOLE PERCENTAGES ONLY, MUST TOTAL 100%)
THE INVESTMENT OPTIONS LISTED ON THIS APPLICATION ARE ONLY AVAILABLE IN VARIABLE
ANNUITY INSURANCE PRODUCTS ISSUED BY LIFE INSURANCE COMPANIES OR, IN SOME CASES,
THROUGH PARTICIPATION IN CERTAIN QUALIFIED PENSION OR RETIREMENT PLANS. THEY ARE
NOT OFFERED TO THE GENERAL PUBLIC DIRECTLY.
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AMERICAN CENTURY VARIABLE XXXXXX XXXXXXX XXXX XXXXXX NATIONWIDE SEPARATE
PORTFOLIOS, INC. ACCOUNT TRUST (CONT.)
______% Xxxxxx Xxxxxxx Xxxx Xxxxxx ______% Nationwide High Income Bond Fund
______% American Century VP Income & Universal Funds-Emerging (Federated Investment Counseling,
Growth Markets Debt Portfolio Inc.)
______% American Century VP ______% Xxx Xxxxxx Life Investment
International Trust-Xxxxxx Xxxxxxx Real ______% Nationwide High Income Bond
______% American Century VP Value Estate Securities Portfolio Fund (Federated Investment
DREYFUS NEUBERGER & XXXXXX ADVISORS MANAGEMENT Counseling)
______% The Dreyfus Socially TRUST
Responsible Growth Fund, Inc. ______% AMT Guardian Portfolio ______% Nationwide Multi Sector Bond
______% Dreyfus Stock Index Fund, Inc. ______% AMT Mid-Cap Growth Portfolio Fund (Salomon Brothers Asset
______% Dreyfus Variable Investment ______% AMT Partners Portfolio Management, Inc. with Salomon
Fund - Capital Appreciation XXXXXXXXXXX VARIABLE ACCOUNT FUNDS Brothers Asset Management
Portfolio ______% Oppenheimer Aggressive Growth Limited)
FEDERATED INSURANCE SERIES Fund/VA
______%Federated Quality Bond Fund II ______% Oppenheimer Capital ______% Nationwide Select Advisers
FIDELITY VARIABLE INSURANCE PRODUCTS FUND Appreciation Fund/VA Mid Cap Fund (First Pacific
______% VIP Equity-Income Portfolio: ______% Oppenheimer Main Street Growth Advisors, Inc., Pilgrim Xxxxxx
Service Class & Income Fund/VA & Associates Ltd. & Rice,
______% VIP Growth Portfolio: Service WARBURG PINCUS TRUST Xxxx, Xxxxx and Associates)
Class ______% Growth & Income Portfolio
______% VIP High Income Portfolio: ______% International Equity Portfolio ______% Nationwide Select Advisers
Service Class ______% Post-Venture Capital Portfolio Small Cap Growth Fund
______% VIP Overseas Portfolio: NATIONWIDE SEPARATE ACCOUNT TRUST (Franklin Advisers, Inc.,
Service Class (SUBADVISORS) Xxxxxx Xxxxxxxx & Xxxxxxxx,
FIDELITY VARIABLE INSURANCE PRODUCTS FUND ______% Capital Appreciation Fund LLP, Xxxxxxxxx Xxxxxx, LLC)
II ______% Government Bond Fund
______% VIP II Contrafund Portfolio: ______% Money Market Fund ______% Nationwide Small Cap Value
Service Class ______% Total Return Fund Fund (The Dreyfus Corporation)
FIDELITY VARIABLE INSURANCE PRODUCTS FUND ______% Nationwide Balanced Fund
III (Salomon Brothers Asset ______% Nationwide Small Company
______% VIP III Growth Opportunities Management, Inc.) Fund (The Dreyfus Corporation,
Portfolio: Service Class ______% Nationwide Equity Income Fund Xxxxxxxxx Xxxxxx, X.X., Xxxxxx
XXX XXX WORLDWIDE INSURANCE TRUST (Federated Investment Asset Management, Strong
______% Worldwide Emerging Markets Fund Counseling, Inc.) Capital Management, Inc.,
______% Worldwide Hard Assets Fund ______% Nationwide Global Equity Fund Warburg Pincus Asset
(X. X. Xxxxxx Investment Management, Inc.
Management, Inc.)
______% Nationwide Strategic Growth
Fund (Strong Capital
Management, Inc.)
______% Nationwide Strategic Value
Fund (Strong Capital
Management, Inc., Xxxxxxx
Capital Management, Inc.)
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FEDERAL INCOME TAX WITHHOLDING
A. [ ] I elect to have no income tax withheld from my income payments (do not
complete B or C)
B. [ ] I want my withholding from each income payment to be figured using the
number of allowances and marital status shown (you may also designate an
additional amount in item C)
_____ Allowances [ ] Single [ ] Married [ ] Married, but withhold
at higher single rate
C. [ ] Withhold the following additional amount from each income payment (you
must complete B) $_____________
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CONTRACT OWNER SIGNATURES
Are you a U.S. Citizen? [ ] Yes [ ] No If No, country of citizenship
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I hereby represent my answers to the above questions to be accurate and complete
and acknowledge that I have received a copy of the current prospectus for this
variable annuity contract.
Do you have any reason to believe the Contract applied for is to replace
existing annuities or insurance? [ ] Yes [ ]No
Please send me a copy of the Statement of Additional Information to the
Prospectus. [ ]
STATE IN WHICH APPLICATION WAS SIGNED DATE
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CONTRACT OWNER JOINT OWNER
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Signature Signature
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PRODUCER INFORMATION
Do you have any reason to believe the Contract applied for is to replace
existing annuities or insurance? [ ] Yes [ ] No
PRODUCER SIGNATURE
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Signature
NAME PRODUCER SSN
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FIRM NAME PHONE ( )
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ADDRESS
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REGULAR MAIL EXPRESS MAIL
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Nationwide Life Insurance Co. INCOME PRODUCTS SERVICE CENTER Nationwide Life Insurance Co.
P.O. Box 182290 0-000-000-0000 Income Products Service Center,
Columbus, Ohio 42272-4875 Fax 000-000-0000 1-14-RO
Xxx Xxxxxxxxxx Xxxxx
Xxxxxxxx, Xxxx 00000
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SEND APPLICATIONS WITH CHECKS TO:
Nationwide Life Insurance Co.
P. O. Box 71-0767
Columbus, OH
43271-0767
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