Electronic Funds Transfer (EFT) Authorization Agreement

For Nationwide's Monthly Automatic Checking/Savings Deduction Plan

I (we) hereby authorize Nationwide to initiate monthly debit entries to my (our) __ Checking Account / __ Savings Account (select one) indicated below at the depository institution named below. I (we) acknowledge that if any of our ACH debit entries are returned unpaid for insufficient or uncollected funds, fees may be applied. This EFT Authorization Agreement is to remain in full force and effect until Nationwide has received written authorization from me (or either of us) of its termination in such time as to afford Nationwide and my (our) depository institution a reasonable opportunity to act on it.

I (we) acknowledge that the origination of an ACH transaction to my (our) account must comply with the provisions of U.S. law.

Your Name(s): ______________________________________________________

Your Nationwide Billing Account Number: _______________________________

Your Depository Name: _______________________________________________

Depository's Routing/Transit Number*: ___ ___ ___ ___ ___ ___ ___ ___ ___

Your Checking/Savings Account Number*: ______________________________
*See below for an explanation of where to locate these two sets of numbers on your bank check.

Effective Date: ___________________

1) Bank Routing/Transit Number
These are usually the first nine digits listed in the bottom left corner of your check as denoted by the number 1 on the
check pictured above.
2) Account Number
The account number is usually the next set of numbers listed after the Bank Routing/Transit Number as denoted
by the number 2 on the check pictured above.
3) Check Number - For Reference Purposes Only
(Matches the number in the upper right corner of check.)