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STATE INSLJRANCE FRAt1D V1'ARNINGS <br /> FOR DC RESIDENTS ONLY: WARNING: it is a crime to provide false or information conceming any fact material thereto commits a fraudulent <br /> misleading information to an insurer for the purpose of defrauding the insurer insurance act,which is a crime and subjects such person to criminal and civil <br /> ^r any other person. Yenalties include impnsonment:u�dlor fines. In addition, penalties. <br /> an insurer may deny insurance benefits if false information materially related FOR WA RESIDENTS ONLY•Any person who knowingly presents a false <br /> to a claim was provided by the applicant. or fraudulent claim for paymenl oC a loss or l:nowingly makes a false <br /> FOR FL RESIDENTS ONLY: Any person who knowingly and with intent statement in an application for insurance may be guilty of a criminal offense <br /> to injure, defraud, or deceive any insurer files a statement of claim or an under state law. <br /> application containing any false, incomplete, or misleading information is NOTICE TO AR, CO. KY, LA, ME, NM, OH, AND TN RESIDENTS <br /> 6uilty of a felony of the third degree. ONLY: Any person wlio, l:nowingly and with intent to injure, defraud or. <br /> FOR NJ RESIDENTS ONLY: Any person who includes any false or deceive any insurance company or other person, files an application for <br /> misleading information on an application for an insurance policy is subject to insurance or statement of claim containing�ny materially false information or <br /> cnminal and civil penalties. conceals for the purpose of misleading, information conceming any fact <br /> NOTICE TO OK AND PA RESIDENTS ONLY: Any person wlio material thereto commits a fraudulent insurance act,which may be a crime and <br /> knowingly and with intent to defraud any insurance company or other person may subject such person to criminal and civil penalties,fines,imprisonment, <br /> files an application For insurance or statement of claim containing any or a denial of insurance benefits. <br /> materially false information or conceals for the purpose of misleadin�, <br /> ADDTTIONAL STATE NOTICES <br /> NOTICE TO MN RESIDENT'S ONLY:This Contract is not protected by the Minnesota Life and Health Insurance Guaranty Association or the Minnesota Insurance <br /> Guaranty Association. In the case of insolvency,payment of claims(except for the Fixed Account,if elected)is not guaranteed. Only the assets of the Insurer will be <br /> available to pay your claim. <br /> NOTICE TO FL,MN,ND.SC.SD,TX AND VT RESIDEN'I'S ONLY:Annuity payments,death benefits,surrender values,and other Contract Values aze variable <br /> when based on the investment exparience of a separate account,or in the case of the Fixed Account,if elected, subject to a mazket value adjustment, and aze not <br /> guaranteed as to fixed dollaz amount,unless otherwise specified. <br /> Additionally,any benefits,values or payments based on the perfo�nance of the underlying investment options may vary and are NOT guaranteed by Nationwide Life <br /> Insurance Company,or any other insurance company,by the U.S. Government,or any State govemment. They are NOT federally insured by the FDIC,the Federal <br /> Reserve Board or any agency Federal or State. <br /> SIGNATURES <br /> Signed on behalf of �`� �� �e �'� �✓, �L L/��/.5 this 2 n d day of <br /> March ,2�4� 2009 <br /> � �J March 5 , 2009 <br /> [(Authorized� ignature of Appli� Date <br /> Mayor Pro Tem <br /> [(Title)] � � <br /> - �',`'iv 3 � �`0 9 <br /> [( rized Nati wide ent/Representative Sign ture)] Date <br /> ��-r� � <br /> [(Title)] <br /> Florida License Identification#:(Fiorida Agents only) <br /> NRA-0104A0 2 (3001-Standard)(9/2007) ', <br />