Retirement Plan Specialists, Inc. provides a free initial consultation and retirement program design. To request this, complete the form below and we will have a representative contact you. The more data you provide, the more detailed our analysis will be. Specifically, if you have an existing plan, please provide a SPD or plan document.

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REQUEST FOR INFORMATION

Employer Legal Name
Street Address

City

State... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip Code

County

Mailing Address

Telephone

Fax

Contact Person

Email Address

Type of Employer Organization (For tax purposes)
For Profit		Not For Profit
C Corporation	Partnership	Government Entity	Charitable
S Corporation	Sole Proprietor	Church	Other
Professional Service		Educational

Date Business Began		Date of Incorporation
Fiscal Year Ends		Nature of Business
NAIC Business Code		Employer Tax ID Number
Basis of Accounting	Cash Accrual

Plan Design Objectives of Employer

What are the Employer objectives in establishing this plan? (Rank in ascending order starting with 1 for highest priority)
	Tax Deduction for Employer
	Accumulate substantial retirement income for owner(s)
	Create a non-business asset for owner(s)
	Provide retirement security for employees
	Attract and retain employees
	Benefit key employees
	Allow employee pretax savings
	Replace lost IRA deductions
	Transfer of business to family members
	Buyout of major stockholder's interest

When does the Employer intend to adopt the plan?
When does the Employer wish to make the first contribution?
Who do you want as trustee(s) on the plan?

Does the Employer want a specific type of plan and if so what type?

Most Suitable Plan Profit Sharing Plan Defined Benefit Employee Stock Ownership Plan 401(k) Plan SEP/SIMPLE

Check here if allocation of key employees is to be maximized (Cross-tested or integrated)

Who does the Employer want to be eligible for this plan?
	All employees initially eligible
	All employees employed on___________date are eligible
	Waiting period of _______________months and attainment of age___________
	Exclude: ___________________________________________________________
Notes:

Ownership, Affliliated Organization and Family Information

Provide the ownership breakdown of the business for the plan year being valued. For a corporation, provide the breakdown of stock ownership. For a not-for-profit organization, skip this section. For a non-incorporated business, provide the capital or profit interest breakdown.
NAME	STOCK %
	100%
Does the Spouse of any controlling owner have an ownership interest in any other business?	Yes No

Family Members

Important - Currently, family members (lineal ascendants/descendents and spouses thereof) who are employed and participating in the plan(s) can, under certain circumstances, be tagged as highly compensated and/or key employees. Therefore, the following information must be completed. Are any employees related (spouse, child, parent, grandparent, grandchild, or in-laws) to any of the following (Highly Compensated or HCE) or Key Employees, defined as:

A 5% or more owner

An employee earning over $85,000

Name	Related to	Type of Relationship
Name	Related to	Type of Relationship
Name	Related to	Type of Relationship

Existing Plan

(If possible, send a copy of the Plan Document and/or Summary Plan Description with this questionnaire)

What type of plan does the employer currently have?
Effective Date of Plan	Trust EIN
Will the plan under consideration replace, enhance or supplement the existing plan(s)?

Check areas of concern, if any, with the existing plan:

Analysis in light of objectives indicated

Requires redesign due to changed business circumstances

Review administrative services

Review of plan for compliance with recent legislative changes

Does the Employer have a health plan that is partially funded by employee contributions?	Yes No
If yes, does Employer want a quote on a Section 125 Cafeteria program?	Yes No

Client Advisors

Accountant
Company
Address
Phone
Phone 2
Fax
Email
Attorney
Company
Address
Phone
Phone 2
Fax
Email
Investment Advisor
Company
Address
Phone
Phone 2
Fax
Email
Insurance Agent
Company
Address
Phone
Phone 2
Fax
Email

Employee Census

Employee's Name	Sex	Date of Birth	Date of Hire	Gross Compensation	Date of Termination	Hours Worked	Salary Deferral %

 

Verification Code