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FINANCIAL HARDSHIP APPLICATION

All information must be completed and documents must be attached in order for this Financial Hardship Application

request to be processed.

The information contained in the application shall be treated as confidential and shall be used only to determine this severe

hardship request.

PARTICIPANT NAME: _________________________________________________________________ SSN:________________________

CURRENT ADDRESS: _______________________________________________________________________________________________

HOME PHONE:

WORK PHONE:

MARITAL STATUS: ____________________

NO. DEPENDENT CHILDREN: ___________

NO. OTHER DEPENDENTS: ___________

EMPLOYER: _____________________________________________

JOB TITLE: _____________________________________________

AMOUNT CURRENTLY BEING DEFERRED PER PAY PERIOD: ______________________

Please respond to the following:

1. Would discontinuing deferrals relieve the severe financial hardship? . . . . . . . . . . . . . . . . . . . . . . q YES

q NO

2. If the first question was answered “NO”, indicate the

amount needed to meet the severe financial hardship: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $________________

3. Do you wish to continue having deductions taken for the Deferred Compensation Plan?. . . . . . q YES

q NO

If you have checked “NO”, please contact Nationwide Retirement Solutions at (410) 252-7201 or 1-800-966-6355 to cease the

deductions; the change will be become effective with the first available pay period, subject to the Payroll Center’s processing

schedule.

NOTE: If you elect to terminate your deferrals at this time, a new application must be completed in order to re-enroll in

the Plan, subject to the restrictions of your Plan Document.

4. Please state in your own words what event has occurred since you enrolled in the Plan which has caused this severe

financial emergency. (Attach additional pages if space provided is insufficient). PLEASE ATTACH SOME

DOCUMENT(S) WHICH SHOWS PROOF OF THIS EMERGENCY. For samples of such documents, see Financial

Hardship Instructions.

_______________________________________________________________________________________

5. Have you considered the following sources for the needed funds?

a. Credit Union. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . q YES

q NO

b. Bank . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . q YES

q NO

c. Savings & Loan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . q YES

q NO

d. Sale of assets. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . q YES

q NO

If you responded “NO” to any of the above options, or if you considered any of these sources and were either turned down or

unable to sell certain assets, please explain WHY this occurred.

_______________________________________________________________________________________

6. Please state whether any of the events described in your answer to question 4

q YES

q NO

are covered by a policy of health or casualty insurance which is currently in force.

If you have checked “YES”, please state the amount of insurance proceeds that

$________________

you expect to collect.

DC-1353-0313

Page 2

Form Dc-1353-0313 - Financial Hardship Request Instructions And Application Form Maryland Page 2

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