Retirement Plan Specialists, Inc.

Employee Benefit Administrators, Actuaries and Consultants

Request for Information

(Confidential)

Fax or mail the completed questionnaire and the attached employee census to the address indicated below.

EMPLOYER LEGAL NAME_________________________________________________________________________________

STREET ADDRESS_________________________________________________________________________________________

CITY____STATE_ZIP CODECOUNTY____

MAILING ADDRESS (if different)____________________________________________________________________________

TELEPHONE NUMBER ____________________FAX NUMBER_________________CONTACT PERSON_______________

EMAIL ADDRESS __________________________________________________________________________________________

TYPE OF EMPLOYER ORGANIZATION (For tax purposes):

FOR PROFIT NOT FOR PROFIT [ ] C Corporation [ ] Partnership [ ] Governmental Entity [ ] Charitable

[ ] S Corporation [ ] Sole Proprietor [ ] Church [ ] Other

[ ] Professional Service [ ] Educational

________________ _________________ _____________ ___________________________________

Date Business Began Date of Incorporation Fiscal Year Ends Nature of Business (e.g. attorney, car dealer)

________________________ _____________________

NAIC Business Code (6 digits) Employer Tax I.D. Number Basis of Accounting [ ] Cash [ ] Accrual

PLAN DESIGN OBJECTIVES OF EMPLOYER

What are the Employer objectives in establishing this plan?

(Check those that apply; 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?_______________________________________________________

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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 to 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: ______________________________________________________________________

OWNERSHIP, AFFILIATED 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? ______ (Y, yes or N, 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: ___________________

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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? __________

If yes, does Employer want a quote on a Section 125 Cafeteria program? ______

CLIENT ADVISORS

Accountant _______________________________________ Attorney ______________________________________________

Company _________________________________________ Company______________________________________________

Address___________________________________________ Address_______________________________________________

_________________________________________________ _____________________________________________________

Phone ( ) __________________/Ext._________________ Phone ( ) ___________________/Ext.____________________

Fax ( ) _______________E-Mail_____________________ Fax ( ) _______________E-Mail _______________________

Investment Advisor_________________________________ Insurance Agent _______________________________________

Company _________________________________________ Company_____________________________________________

Address___________________________________________ Address______________________________________________

___________________________________________________ ____________________________________________________

Phone ( ) _________________/Ext.___________________ Phone ( ) __________________/Ext.____________________

Fax ( ) ______________E-Mail_______________________ Fax ( ) _______________E-Mail_______________________

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Employee Census

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

________________________ ________

Signature of Employer Date

Additional Comments: _______________________________________________________________________

__________________________________________________________________________________________

Mail this completed and signed form to the address listed below.

Retirement Plan Specialists, Inc. (RPS)

815 Eyrie Dr., Suite 2, Oviedo, Florida 32765