Plan Name*

Name of Plan Sponsor*

Mailing Address*

Phone*

Cell

Fax

Plan Correspondent (Contact for Plan Information Purposes)*

Contact e-mail address*

Our Company’s Taxable Year ends (MM/DD)*

Employer Identification Number*

Trust Identification Number (if applicable)*

Please complete one of the following

We have elected “C” status (Regular Corporation)

We have elected “S” status (Sub-S Corporation)

Government Entity

Non- Profit 501(c)(3) Entity

Sole-Proprietor

Partnership

Limited Liability Company (LLC)

How have you selected to be taxed?

Sole Proprietor

Partnership

Corporation

Limited Liability Partnership (LLP)

Date of Incorporation or Date Business Started if Not Incorporated

State of Incorporation (if applicable)

Type of business engaged in by Employer

Business Code (six-digit code found on business tax form)

Does Employercurrently maintain any other retirement or cafeteria (section 125) plan?

Yes

Did the Employer ever maintain another retirement plan, whether or not terminated?

Yes

If yes, explain

Total Number of Employees

Do you have any leased employees?

Yes

If yes, how many?

Do you have any independent contractors?

Yes

If yes, how many?

Do you have any collectively bargained employees?

Yes

If yes, how many?

Family Members: provide names of employees who are related, and their relationship, to shareholders, partners, officers and key employees. (Related refers to parents, grandparents, spouses, children and spouses of children.)

Each Trustee (fiduciary) of a qualified retirement plan and every person who handles funds of a plan must be bonded to protect against loss by fraud or dishonesty (unless your Plan covers only owners). This information must be disclosed on your Form 5500 Annual Return. Please provide us with the name of the insurance company and the amount of coverage. If your plan has less than 100 Participants, please refer to the enclosed Small Plan Audit Requirement insert.

Name of Insurance Company

Amount of Coverage

Please list the ownership interest and officers of the Plan Sponsor below: For this purpose, an employee is an officer if he/she is an administrative executive who is in regular and continued service (and not employed for a special and single transaction, or employed for nominal administrative duties).

Does any person, or business concern listed above, or any spouse of any person listed above have ANY ownership in any OTHER business entity?

Yes

If yes, list the owner and officer information on a separate sheet for each business entity.

Are you a member of a Controlled Group or Affiliated Service Group of businesses?

Controlled Group

Yes

Affiliated Service Group

Yes

If so, please provide details.

Miscellaneous

Investment Broker/Agent

Copy of all correspondence to the Broker/Agent?

Yes

Name

Address

E-mail

Phone

Cell

Fax

Accountant

Copy of all correspondence to the Accountant?

Yes

Name

Address

E-mail

Phone

Cell

Fax

Attorney

Copy of all correspondence to the Attorney?

Yes

Name

Address

E-mail

Phone

Cell

Fax

I certify that the above information and all enclosures are accurate and complete.

Signature of Plan Administrator

Date

owner1

Name of All Owners, Shareholders, Partners or Officers

officer1

Officer Yes/No

title1

Officer Title

owned1

Owned (%)

owner2

officer2

title2

owned2

owner3

officer3

title3

owned3

owner4

officer4

title4

owned4

owner5

officer5

title5

owned5

owner6

officer6

title6

owned6

owner7

officer7

title7

owned7

Total Ownership Interest (must total 100%)

Annual Business Questionnaire

Please verify/complete (blank areas) and update (if applicable) and return this form even if no data changes have occurred from last year.

Questionnaire

Miscellaneous

Company

Services

Resources

No Fee Analysis

Articles / Contact